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Maya Healthcare clinic Services Agreement

Insurance

You’re responsible for all medical costs, regardless of insurance. We check benefits as a courtesy, but it’s not a guarantee. You must understand your insurance policy. If insurance doesn’t cover services, you’re still responsible for payment. Notify us of any insurance changes. You authorize insurance to pay us directly.

Prescription Refill Policy

Please schedule a follow-up before your medication runs out. We only handle refills and changes during appointments at Maya Health Care & Behavioral Health Clinic. Missing appointments can disrupt your care and lead to relapse.

Cancellations and Missed Appointments Policy

Please give us at least 24 business hours’ notice if you need to cancel or reschedule an appointment. If you miss or cancel without adequate notice, there’s a $75 charge. This fee isn’t covered by insurance; you’re responsible for it. After three missed appointments, we won’t be able to continue services until all fees are paid.

Returned Checks

A $50 fee applies to all returned checks.

Testifying in Court

If your healthcare provider is summoned to testify in legal matters, like custody cases, you’re responsible for covering travel expenses and hourly fees. These fees are based on our standard rates from when the provider leaves until they return. We expect at least 50% of the estimated cost before the court appearance, regardless of which side sends the subpoena.

Communication

We often use phone, email, and text for scheduling, billing, refills, and other service-related matters. While we encrypt our electronic communication, we expect you to protect your end (e.g., using a PIN for voicemail or password for email). If you’re not comfortable with electronic communication or it’s not secure on your end, please refrain from scheduling appointments with us.

Danger

In case your provider believes you pose a risk to yourself or others, by signing this consent, you allow her to contact your emergency contact or another person for help during a crisis.

Right to Withdraw

If there’s a conflict between the client and the physician/provider, either party can choose to stop the treatment. If the provider decides to withdraw, she will inform the client and offer suitable referrals along with 30-day emergency care.

Confidentiality:

At Maya Health Care & Behavioral Health Clinic, we keep your information private according to Texas law. However, there are some cases where we must share information:

We report any signs of child abuse.
If someone is in danger, we inform authorities.
Sexual misconduct by a former therapist or psychiatrist is reported.
Legal actions like custody cases may require disclosure.
We may share information for fee collection purposes.

If you have questions, talk to your provider.

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