Welcome to Northridge Behavioral. We appreciate the opportunity to work with you. The following information is provided for your benefit so that we may serve you better. Please read carefully and sign at the bottom of page 2. You will be given a copy foryour records.

Fees for services: which include unpaid balances, deductibles; copayments and fees are due at the time of your visit. We accept cash, debit, and all major credit cards.

We ask that you arrive on-time for your appointments. This will facilitate our ability to see you as scheduled. Patients arriving past the appointment time may result in rescheduling.

NEW PATIENTS: A reservation fee of $125 is required to schedule your first appointment. For those with in-network insurance, this fee may be refunded to you at your first appointment (depending on your insurance plan/coverage); you will then be charged for your visit in accordance with your insurance plan/coverage. For private/self-pay patients (including those out-of-network insurance), the registration fee is applied to your New Patient appointment and the remaining balance is due at the time of your visit.

NEW PATIENTS: are asked to cancel their first appointment not less then 3 business days before their scheduled appointment by speaking with someone in our office directly. Late cancellation of your appointment will result in your $125 reservation fee not being refunded. EXISTING PATIENTS: patients are asked to cancel at least 24 hours in advance of the scheduled appointment time. The charge for a noshow for an appointmentis $100. This charge is not payable by insurance and I understand that this will be my responsibility.

Please provide us with any change regarding your address, phone number or insurance information as soon as possible.

Must be seen monthly for refills.

Urine prescription monitoring will be conducted on all new patients and periodically on patients taking controlled substances. Patients with drug screens positive for elicit substances will not be prescribed medications that are potentially habit forming.

In a life-threating emergency, please call 911.Forurgent not-emergency matters please call our office number 210-4753048 and leave a message. If needed the provider on call will return your call as soon as possible.

Requests for copies of your medical records must be made in writing on a form provided by our office. Our office will respond within 15 business days to a properly completed written request. Fees: As per the rules adopted by the Texas State Board of Medical Examiners: $25 for the first 20 pages, $.50 cents for each page thereafter. No charge Doctor to Doctor/Hospital. Charges will be assessed for letters and completion of form.

The provider reserves the right to terminate the doctor/patient relationship at their discretion. Reasons for termination may include, but are not limited to: failure to comply with treatment plan, ultimately unpaid balances, history of missed appointments, tampering or refusal of drug screen, verbal abuse of staff and lack of a good fit. The patient (or the patient’s legal representative) has the right to terminate treatment at his/her discretion. Upon either party’s decision to terminate the relationship, the provider will continue care for at least 30 days and recommend more appropriate resources.

Dr. Ajufoand the providers/staff with Northridgedo not participate in court-related matters, such as divorce or child support cases. However, if court-related work is required, the practices’ cost related to that work is the sole responsibility of the patient and/or their responsible party. These matters include but are not limited to: preparation, communication with involved parties, depositions, testimony, standby efforts, attorney fees, and other cost incurred as a direct result of the matter.

In the event of a delinquent account balance, I will be responsible for all collection fees assessed by the collection agency onto the account.

I consent to evaluation and treatment of myself, my minor child or ward.

I hear by authorize my insurance benefits to be paid directly to Dr. Ajufo –Northridge Behavioraland understand that I am financially responsible for non-covered services. I also authorize Northridge Behavioralto release any information to my insurance company required to process claims.