NEW PATIENT FORMS
Please download the following new patient forms for your appointment. If you are unable to complete the paperwork prior to your appointment, please arrive 20 minutes early. Arriving without paperwork and/or late may result in the need to reschedule your appointment. *You have the option to fill out an online editable PDF version, or you may download and bring in your paperwork to your appointment*
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| Zack Adolescent NP Forms |
Miscellaneous Forms
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Please be aware that record requests can take up to 30 days to process. Records released to clients directly will be assessed a $25.00 fee.
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Review of our Office Policies
These office policies may be subject to change without notice
APPOINTMENTS:
If you are interested in scheduling a new patient appointment, please fill out an inquiry online. Someone from our office will contact you within 2 business days. To reduce the amount of no shows or late cancellations, all new patients are required to pay a $60 deposit to reserve their new patient appointment. This money will be applied to your account as a credit.
Your $60 deposit will be forfeited if one of the following occur:
In cases of emergency, please dial 911 or go to the nearest emergency room. You may also contact the crisis hotline at (844) 398-8252. We do not do medication changes or authorize refills over the weekend.
BILLING AND PAYMENT:
While most Austin area psychiatrists are private pay, we choose to accept insurance at a great cost to income and staff time.
While payment is due at the time of service, often unpaid balances accrue. It is our policy that as soon as an unpaid balance reaches $200.00 (three-hundred dollars), no further services will be provided until the balance has been cleared. We will provide one month of your current medication to allow you time to find a new provider. It will be the decision of the provider if they wish to begin the working contract again once the balance is paid. Please note that patients are welcome to set-up a payment plan by authorizing a monthly charge to a credit card to bring their balance below $200.00. However, should the patient violate the payment agreement, the contract is considered null and void and services will terminated. A patient must have active activity on their account, otherwise, the account is subject to collections.
MEDICATION REFILLS:
Prior to calling our clinic, we ask all patients to have their pharmacy electronically submit or fax a refill request to (512) 328-8222 (even if there are no refills on file). Upon request, we will authorize refills when appropriate. You may also submit refill requests to: Refills@austinfamilymentalhealth.com. Please allow 2-3 business days to process these requests. Patients are to call us when they have at least 2-3 days worth of medications at hand.
FMLA AND DISABILITY FORMS:
We do not fill out Short-Term Disability paperwork. We will consider completing FMLA forms after you have been an established client for a minimum of 6 months.
It is impossible for a provider to know the circumstances that make it necessary for a patient to take leave from work. It is your responsibility to work with your employer (likely through Human Resources) to obtain the necessary paperwork for your employer to provide your disability pay. We ask that you obtain a short-term disability assessment through an independent evaluator, such as a Clinical Psychologist Or Clinical Neuropsychologist. When it is necessary for a provider to fill out FMLA, we will be glad to discuss if we feel the need is appropriate and if we can be helpful. However, an appointment must be scheduled so you and your provider can discuss the information requested. A $50 fee is typical for each form submitted. This payment is required prior to submission. There is a 2 week turn around for requested paperwork. We will not rush any documentation.
Our goal is to help our patients on leave and disability improve their emotional health and get back to normal functioning and work status as soon as possible, this may include recommendation for DBT/IOP during leave.
If you are interested in scheduling a new patient appointment, please fill out an inquiry online. Someone from our office will contact you within 2 business days. To reduce the amount of no shows or late cancellations, all new patients are required to pay a $60 deposit to reserve their new patient appointment. This money will be applied to your account as a credit.
Your $60 deposit will be forfeited if one of the following occur:
- If you no show to your scheduled appointment
- Fail to give us 48 hours notice of cancellation
- If you are more than 10 minutes late to your appointment which results in us having to reschedule you to another day.
- In consideration of all patients, individuals who arrive 10 minutes late may need to reschedule their appointment.
- Appointments must be cancelled 24 business hours in advance to avoid a missed appointment fee. The fees are as follows: 30 min. -$125-150, 50min. - $175-200, and group $80.
- Missed appointment fees must be paid prior to the next appointment.
- 3 missed appointments will result in the termination of our professional relationship.
- Although our EMR software will send you an automated reminder, It is the responsibility of the patient to attend follow-up appointments.
- We encourage patients to make or move up an appointment when a complaint or a problem occurs with regard to their mental health.
In cases of emergency, please dial 911 or go to the nearest emergency room. You may also contact the crisis hotline at (844) 398-8252. We do not do medication changes or authorize refills over the weekend.
BILLING AND PAYMENT:
While most Austin area psychiatrists are private pay, we choose to accept insurance at a great cost to income and staff time.
- Payments, co-payments, co-insurance, deductibles, and balances are due at the time of service. You may be asked to reschedule if you do not make payment at the time of service.
- Our office only submits claims to insurance companies for which we are “in-network,” such as: Blue Cross Blue Shield PPO, CIgna, OPTUM, Magellan, ComPsych. We will provide you with a receipt if you are seeking "out-of-network" reimbursement.We do not bill companies in which we do not participate. Our self-pay rates are:
Dr. William Holcomb: $350 evaluation and $150 follow-up; Nurse Practitioner's: $250 evaluation and $125 follow-up - Failure to provide current insurance information could result in patient responsibility of payment in full for services provided.
- Outstanding accounts will be turned over to collections after 90 days of no payment. Once the account is turned over to collections, services will be discontinued.
While payment is due at the time of service, often unpaid balances accrue. It is our policy that as soon as an unpaid balance reaches $200.00 (three-hundred dollars), no further services will be provided until the balance has been cleared. We will provide one month of your current medication to allow you time to find a new provider. It will be the decision of the provider if they wish to begin the working contract again once the balance is paid. Please note that patients are welcome to set-up a payment plan by authorizing a monthly charge to a credit card to bring their balance below $200.00. However, should the patient violate the payment agreement, the contract is considered null and void and services will terminated. A patient must have active activity on their account, otherwise, the account is subject to collections.
MEDICATION REFILLS:
Prior to calling our clinic, we ask all patients to have their pharmacy electronically submit or fax a refill request to (512) 328-8222 (even if there are no refills on file). Upon request, we will authorize refills when appropriate. You may also submit refill requests to: Refills@austinfamilymentalhealth.com. Please allow 2-3 business days to process these requests. Patients are to call us when they have at least 2-3 days worth of medications at hand.
- Prescriptions requested to be filled the same day will be assessed a $20 fee.
- Refills on ADHD prescriptions that are requested between appointments will be assessed a $12 fee.
- There is a $15 fee on mail order prescriptions and for controlled medications (i.e. Clonazepam, Ambien, ADHD medications, and Suboxone) which require a new prescription to be phoned/faxed into the pharmacy.
- Medications taken more than prescribed will be denied an early refill. If you would like to discuss a change in medication, please call the office to set up an appointment.
- Texas law requires patients to be under medical supervision when taking controlled medication. You may be required to see your Provider before your medication is refilled if you have missed your prior appointment(s). Patients on controlled medications are required to see their provider every 90 days.
- Our office does not refill medications after hours.
FMLA AND DISABILITY FORMS:
We do not fill out Short-Term Disability paperwork. We will consider completing FMLA forms after you have been an established client for a minimum of 6 months.
It is impossible for a provider to know the circumstances that make it necessary for a patient to take leave from work. It is your responsibility to work with your employer (likely through Human Resources) to obtain the necessary paperwork for your employer to provide your disability pay. We ask that you obtain a short-term disability assessment through an independent evaluator, such as a Clinical Psychologist Or Clinical Neuropsychologist. When it is necessary for a provider to fill out FMLA, we will be glad to discuss if we feel the need is appropriate and if we can be helpful. However, an appointment must be scheduled so you and your provider can discuss the information requested. A $50 fee is typical for each form submitted. This payment is required prior to submission. There is a 2 week turn around for requested paperwork. We will not rush any documentation.
Our goal is to help our patients on leave and disability improve their emotional health and get back to normal functioning and work status as soon as possible, this may include recommendation for DBT/IOP during leave.