Important Policies and Patient Rights
Statement of Non-Affiliation
Although Lakeside Life Center has multiple healthcare providers working in the same building and may on occasion engage in collaborative activities for the welfare of clients, each provider is separate and independent of the Lakeside Life Center organization and is responsible for their own activities and affairs. Lakeside Life Center does not direct, supervise, or control the independent healthcare providers and is not responsible for their acts or omissions.
- I certify that the information I have given on this form is true and correct to the best of my knowledge.
- I understand that payment is required at the time services are rendered and I assume responsibility for this. I understand that there is a $30.00 fee for all returned checks. (Note to divorced parents: Payment is the responsibility of the parent who brings the child into the office for treatment, regardless of the terms outlined in the divorce decree. The divorce decree is a matter between the divorced parents and the courts, and we cannot be placed in the middle.)
- I understand that insurance will only be filed with insurance companies that the physician, psychiatrist, psychologist, or counselor is contracted with. In order to achieve this, I must have all current insurance information on file. I understand that secondary insurance is not filed.
- I understand that all information obtained with regards to my insurance coverage is not a guarantee of payment by my insurance company. The amount collected at the time of service is only an estimate. I understand that I am ultimately responsible for any and all balances in my account.
- I understand that it is my responsibility to keep my appointments. If I am unable to keep my appointments, I will notify the office at least 24 hours in advance.
- I understand that I will be charged $50 for the time reserved if I do not call and cancel or reschedule at least 24 hours prior to my scheduled appointment.
- I understand that regular office hours are Monday-Friday, 8:30 a.m. to 5:00 p.m.
- I understand that it is my responsibility to keep track of my medication supply. I understand that I should request refills during regular office hours and that requests will not be called into the pharmacist until the next business day.
- I understand that my records are protected by special laws governing psychiatric/substance abuse records and that I must sign a Release of Information before any records can be released.
- I hereby authorize the physician, psychiatrist, psychologist, or counselor to provide psychiatric services to the patient.
Complaints may be reported to: Texas State Board of Medical Examiners
ATTN: Investigations 1812
Centre Creek Dr., Suite 300 P.O. Box 149134
- To be treated with dignity and addressed in a respectful manner.
- Consistent, quality care by qualified and trained professionals in clean, safe settings.
- Humane care and treatment free of abuse, neglect, humiliation, threats or exploitation
- Privacy of your treatment and your records.
- To be informed of the risk, benefits, and alternatives to medications and/or therapy.
- To consult with another licensed practitioner at your own expense.
- To make a complaint or grievance.
- The same legal rights and responsibilities as all citizens, unless otherwise indicated by law.
- The right to be free from discrimination due to race, age, color, religion, national origin, gender, disability, sexual orientation, or marital status.
- Please notify your physician, psychologist, or counselor immediately of any concerns, questions or feedback you may have regarding your sessions and your care.
- Keep appointments and, when unable to do so for any reason, notify your counselor or physician's office with at least 24 hours' notice prior to your appointment. You will be charged the full amount of your appointment if you do not cancel within 24 hours.
- To pay a fee of $25 for any medications if requested on the same day.
- To pay a fee of $30 for treatment reports you request on your behalf and/or for copies of your records.
- All co-pays, fees, or charges will be collected at the time of service. There is a $30 fee for all returned checks.
- To maintain a clean office environment - avoid bringing any food or drinks into Lakeside Life Center.
- To maintain safe settings by not bringing weapons. non-prescribed drugs or alcohol on the premises of Lakeside Life Center.
- Treat your physician, psychiatrist, or counselor, and the office staff and furnishings with respect and follow all posted office rules.
- Maintain supervision and responsibility for your children and family while in our office.
- Pay for any damages caused by the careless, reckless, or intentional behavior of you or your family members.
- Provide accurate and complete information about current problems, past illnesses and treatments, and other pertinent information.
- Inform us if you are receiving counseling, medications, or other therapeutic services from another clinician.
- Participate in treatment decisions and follow the agreed-upon plan or recommendations.
- Check with your physician, psychiatrist, psychologist, or counselor's office about your appointment if inclement weather is forecasted.
- You may be referred to another physician, psychiatrist, psychologist, or counselor for failing to follow these responsibilities.
I understand that Nishendu M. Vasavada, M.D., PA, is not contracted with any managed care insurance and does not file claims. I understand that I am responsible for payment at the time of my visit. I understand that if I file my own claim and payment is made, any adjustments will not be made to my account regardless of what is stated in my explanation of benefits. I understand the Lakeside Life Center does not accept insurance payment.