Roopa Kurse, M

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					GREENWOOD PSYCHIATRY
Roopa Kurse, M. D.
7960 S University Blvd, Ste 202
Centennial, CO 80122
Tel: Office: 720-489-0897; Fax: 303-221-3324

                     Consent for Evaluation and Treatment and Payment contract

In consideration for receiving treatment and psychiatric service, I/we agree to the following:

FEE PAYMENT:
Patients are seen on a fee for service basis only. That is patient or parent is responsible for payment in full at the time
of each appointment. The fee is $ 300 for the initial evaluation session for children and adolescents and $270 for
adults. The initial evaluation is for 90 minutes. Subsequently the sessions are for 50 minutes and the fee will be $ 200
for children and adolescents and $180 for adults. It may take from 2 to 4 subsequent sessions to diagnose and offer
treatment for some clients depending on the complexity of the situation and client. Once a client is established and
consents to psychotherapy (as needed) on a weekly basis the cost will be $175 for each session. For medication follow
up only the fee will be $105 for a 25 min appointment and $200 for a 50 minute appointment. Returned checks will be
assessed a $50 fee.

The parent or patient must pay all fees within 10 days of the receipt of bill. If payments are not made within 30 days of
the services provided, the fees will accrue interest at the rate of 18% per annum, compounded monthly. In addition, a
$20 billing charge/late fee per appointment will be assessed. Bills can only be sent to one address per patient. If
payment is not received, the account will be turned over to a collection agency in 30 days. Dr.Kurse has the option to
pursue all lawful collections procedures available and the patient will be responsible for all reasonable costs of
collection, including all reasonable attorneys’ fees incurred, if any. A minimum collection fee might apply. Unwillingness
to pay may result in termination of services.

Policy of using credit cards for payment:
If you choose, you may use credit card for payment. Dr. Kurse accepts all major credit cards. Dr. Kurse uses a service
called Therapy Partner to bill your credit card. Please complete the information in another form about your credit card
and whenever you are billed, an e mail will be sent to you automatically. If payments are more then 45 days overdue
from the date of service, you agree to have Dr. Kurse bill your credit card for the balance.

CANCELLATIONS:
Appointments made and not kept are billed to you, the patient. Your Insurance Company will not reimburse for any
portion of missed appointments. Cancellation notification must be given at least 24 hours before your appointment. The
fee for missed appointment is $200 for a 50 minute session, $105 for a 25 min session.

INSURANCE:
Many insurance plans reimburse for some portion of psychotherapy and medication management. Please direct your
questions about reimbursement amounts and timeliness to your insurance company. Please be aware that Dr. Kurse’s
fees might be greater than what your insurance will pay.

Dr. Kurse is not contracted (in network, preferred provider) with any insurer. She will provide you with a super bill at
your appointment that you may submit to your insurance. Please note that Dr. Kurse will not complete any insurance
paperwork.

LEGAL ISSUES:
Patient/Parent is responsible for any legal charges or attorney fees should Dr. Kurse be requested for an opinion in the
court or for a report to the court regarding patient.

RECORDS:
Requests for records are received from various sources. Attention to these requests will occur only if the patient or
patient’s parents (younger than 15) have completed a signed Release of Information form. Records 5 or fewer pages



Payment Contract & Consent for Evaluation/Treatment                                                                 Page 1
are copied and mailed free of cost. Records over 5 pages will be copied at $0.20 per page plus postage and billed
directly to you.

INFORMING PRIMARY CARE PHYSICIAN:
In order to ensure the highest level of care to patients, Dr. Kurse will fax or mail a brief note to your primary care
doctor, including treatment recommendations and medications. If you do not want your primary care doctor to be
involved in your psychiatric care, you could indicate that by initialing your name and refusal here. _____________

TELEPHONE CALLS:
Telephone calls are welcome and will be returned promptly on the same or next business day. There will be no charge
for brief phone calls, however calls lasting for longer than 5 minutes will be charged directly to you on a prorated basis
of the hourly fee (minimum $25).

If you have an urgent matter that needs attention you could page Dr. Kurse. Please follow the instructions on Dr.
Kurse’s office voicemail. Most pages will be returned within the hour. If you have a medical or psychiatric emergency
that is life threatening, please call 911 or go to your nearest emergency room. You could have Dr. Kurse paged from
the Emergency room. Please do not use the pager for non urgent matters like prescription refill.

EMAILS AND TEXT MESSAGES: Dr. Kurse will not ascribe to the safety and privacy of e mail messages and text
messages. If you choose to e mail or text Dr. Kurse, you will do so at your own risk to privacy. Dr. Kurse will try and
respond appropriately but please be aware of the risks involved and also the fact that your message might not be
viewed and responded to as she responds to emergent or urgent messages.


CHARGES FOR OTHER SERVICES:
If a client needs services like meetings with school, written reports to school or other physicians, insurance company,
etc you will be charged the usual prorated hourly fee.

PLEASE NOTE THAT PRACTICE STANDARDS REQUIRE THAT ALL PATIENTS BE SEEN, AT MINIMUM EVERY
THREE MONTHS.


I HAVE READ THE ABOVE INFORMATION REGARDING THE TERMS OF TREATMENT CONTRACT. I
UNDERSTAND THE TERMS OF PAYMENT AND TREATMENT AND WILL ADHERE BY THEM.


Patient name ______________________                           Δ Patient
                                                              Δ Parent
Guarantor for payment_________________________                Δ Guardian
   Please Print                                               Δ Other


Guarantor signature ____________________________


I AGREE FOR LIMITED INFORMATION, AS NECESSARY TO BE SHARED WITH ANOTHER CLINICIAN IN ORDER
TO FACILITATE MY/MY CHILD’S TREATMENT.

Patient name ______________________                           Δ Patient
                                                              Δ Parent
Guarantor for payment_________________________                Δ Guardian
                      Please Print                            Δ Other


Guarantor signature ____________________________



Payment Contract & Consent for Evaluation/Treatment                                                                  Page 2
Payment Contract & Consent for Evaluation/Treatment   Page 3

				
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