аЯрЁБс>ўџ ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџ§џџџўџџџўџџџ  §џџџ !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~€Root EntryџџџџџџџџВZЄ žбЄРOЙ2КzіqЪАCONTENTSџџџџ XCompObjџџџџџџџџџџџџVSPELLINGџџџџџџџџџџџџhўџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџy prescription, you will be charged a $10.00 fee. Please note during business hours it is more effective to reach us by our office number, pagers are for after business hours. RETURNED CHECKS: It is policy of this office to charge a fee of $25.00 for all returned checks. Once an account has a return check fee charge to it, regardless of reason, only cash or credit card will be accepted. APPOINTMENTS: If you are unable to keep an appointment, please notify our office immediately. If an appointment is missed without 24 hour notice there will be a charge of $45.00. We do call the day before as a reminder, and may leave a message on your answering machine, or with a responsible party in your household, unless you specifically request us not to do so. With or without an answering machine or other party telephone reminder, you are still responsible for canceling with 24 hours notice, or you will be charged. Please note insurance carriers do not pay for cancelled or missed appointments. PAYMENTS: As a courtesy to you, Cary Behavioral Health will accept assignment of any insurance benefits that we are in network with and file health care claims directly to your insurance company. However, payment of all applicable copays and deductibles (or any other amount not covered by your primary insurer) is required at the time services are rendered. Cary Behavioral health Care will not be able to file claims to your insurance company unless you provide us with accurate and complete information about your insurance plan. You must also promptly inform us of any changes in your insurance coverage or will not be able to file your claims. Similarly, many insurance companies are now managing their mental health benefits. This means you must consult your insurance booklet to see CHNKWKS XјџџџџTEXTTEXT’$FDPPFDPP(FDPCFDPC*STSHSTSH,VSTSHSTSHV.dSYIDSYIDК2SGP SGP Ю2INK INK в2BTEPPLC ж2BTECPLC ю2FONTFONT3ЈSTRSPLC Ў3:MCLDMCLDш3˜ѕPRNTWNPR€)X,FRAMFRAMиUˆTITLTITL`V8DOP DOP ˜V"CARY BEHAVIORAL HEALTH PC 160 N.E. MAYNARD ROAD, SUITE # 200, CARY, NC 27513 PHONE (919) 466-7540 FAX (919) 466-7543 POLICIES AND PROCEDURES FEE SCHEDULE: $300.00 Initial Assessment  Dr. Bajwa or Dr. Qureshi $150.00 20-30 Minute Individual Therapy w/Medication Management $200.00 45-50 Minute Individual Therapy w/Medication Management $150.00 Medication Check $150.00 Initial Assessment  Psychotherapy $150.00 50 Minute Individual Psychotherapy $150.00 Family Therapy without Client $200.00 Family Therapy with Client 300.00 ADHD Assessment Testing $ 60.00 Group Therapy $ 25.00 Report/Document Preparation RECORD COPY FEE: To cover the costs incurred in searching, handling, and copying medical records a fee for each request shall be seventy-five cents per page for the first 25 pages, fifty cents per page for pages 26 through 100, and twenty-five cents for each page in excess of 100 pages and a minimum fee of up to ten dollars, inclusive of copying costs, for mailing medical records for the patient or the patients designated representative. MEDICATION HISTORY: With signing of this policy I would be the authorizing Cary Behavioral Health, P.C. to obtain, prescribe and share my medication history with any pharmacy and/or my doctor. TELEPHONE CALLS / PRESCRIPTIONS: Clients may occasionally have the need for crisis intervention by telephone. Telephone charges are based upon the length of the call. There is no charge for calls under 5 minutes concerning side effects of medications prescribed by Cary Behavioral Health. There is a flat rate charge of $10.00 for calls over 5 minutes. We require at least 24 hours notice to refill a prescription faxed in from your pharmacy. However, for all stimulant prescriptions or if we need to call in an emergencif your insurance company must approve sessions before they occur. If this is required you need to acquire authorizations and you are responsible to keep up with number of authorizations allowed and that you have used. If not sure please ask us and we will be happy to assist. Please note that you are ultimately responsible for all charges incurred for your treatment or the treatment for which you are responsible. If for any reason your insurance company, or other third party payer (such as a divorced spouse or lawyer), does not reimburse Cary Behavioral Health for services rendered, you will be responsible for those charges, after 90 days if no payment is made by such parties. I have read the policies and procedures and understand and agree to these policies. ___________________________________________ _____________________ Signature of Patient or Responsible Party Date Signature below is only acknowledgement that you have received Notice of our Privacy Practices. ____________________________________________ ________________________ Print Name and Signature Date still responsible for canceling with 24 hours notice, or you will be charged. Please note insurance carriers do not pay for cancelled or missed appointments. PAYMENTS: As a courtesy48Јў<>ZЦHШњPІђ8xЄьюd f ъ ь œ`dав* \#^#$$ $ $$ђ$є$і$’%И%К%F&Š&Œ&Ž&&’&јјјєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєєЬЬ(2‚"'(Š  л) @ЗS 8<ў <Zьf Ž ь  , d†0аф* Z#Š&Œ&Ž&’&кЖЄvFFvFvFvFvFvFvFvFvFvFфк " . "ˆЖ" $Š 084 "ˆЖ" $Š 080 "PS" $Š 08. "PS" $Š 08 "ˆЖ" $ "ˆЖ" $Š& "hC" $ŠB<нЁX^€†Вдєњ,Pt~ˆ’œІАФоќ"џџџџReturn AddressГџџџInside Address NameInside Address Document BodyРџџџДџџџReturn Address NameDefinition TermDefinition ListH1H2H3H4H5H6Address Blockquote Preformattedz-Bottom of Form z-Top of FormP,<нЁАОЦрє*:N\p†šЈМЪцє &<RbxˆžЈОЮфє "0P€дD "№ "  "|О" ."РРР "pЦ *."  "Д!" ."  *"  "Д!" ."   *   "Д!" ."  *"  "Д!" ." "Ј)  *РР  "Д!"   *"  "Д!"   *"  "Р"  ."3f  *" "№" " "№" "ј|"  " І"ј|." " ј" ј ."  "ј| ј " ј" ј ."  "ˆЖ ј " ј" ј ." ј " ј" ј ."  "№ ј " ј" ј ."  "рŒ ј " ј" ј ."  "№ ј  "№ "ј|"ј|" ј" ј, "№$Š  08)P2‚J' (Š@ ХJ  Š• Oр +%( йu.0 žР78 c A@ (VJH э SP Вы\. "рŒ $Š  08йu. 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