As our name implies, we form a PACT with each of our clients to work together to achieve our mutual therapeutic goals. We continuously strive to make each visit a satisfying experience. Please feel free to speak with a member of our staff regarding your experience at any time. Todd Antin, M.D., DFAPA is the founder of PACT Atlanta, LLC. He is board certified in psychiatry, addiction, and geriatrics by the American Board of Psychiatry and Neurology and has been honored as a Distinguished Fellow of the American Psychiatric Association. Dr. Antin has a diverse staff of specialists to assist in your care. These include Dr. David Tascarella, Dr. Richard Bunt, and a variety of Therapists, Clinical Nurse Specialists, Social Workers, and others. As the term suggests, both parties are active participants. The following are some of our office policies which will help to make your experience as constructive as possible.

FINANCIAL POLICIES:
Payment is due at the time of service. However, we are included in many insurance panels and will file for those insurance plans only. It is your responsibility to check to see if your insurance plan accepts our providers. If we do file with your insurance company, you are still required to pay your deductible or co-payment at the time of service. Balances will be allowed only for those patients who first make payment arrangements with our office manager, Suzette White.

PRESCRIPTIONS:
Our office policy requires that all prescription refill requests be made 24 hours in advance and must be requested by your pharmacy. Please do not personally contact the office regarding your prescription refills, unless there are serious extenuating circumstances. This will allow our staff sufficient time to handle all medication refill requests as promptly as possible. The 24- hour advance notice also includes all written prescription requests. If for any reason we cannot refill your prescription you will be notified by phone. Prescription refill requests must be made during normal business hours.

APPOINTMENTS:
A 24-hour notice must be given to cancel an appointment. If no notice or less than 24-hours is given, your account will be charged a missed appointment fee. Please note that most insurance carriers will not pay for missed appointments, thus it is your responsibility.

PHONE CALLS & FAXED MESSAGES:
Each patient will be given one phone consultation per month at no charge. Additional phone calls or faxed messages that require a response from the physician or clinical staff will be billed to the patient. Charges will be assessed by the complexity and length of phone calls. Most insurance carriers will not pay for phone consultations. Therefore, those charges will be the patient’s responsibility.

RETURNED CHECKS:
Any check returned by your bank for insufficient funds will result in a $29 NSF fee. A patient who has a check returned may also be required to pay in cash for all subsequent appointments.

MEDICAL RECORDS:
If you are coming to us from another practice, please sign a release of information so we may have your records sent to us prior to your next appointment. This will assure continuity of care. It is our general office policy to NOT release medical records directly to the patient. We will, however, consider releasing the records to another physician or an attorney so they can be reviewed under supervision.

EMERGENCIES:
In case of a true emergency, contact our office at 404-292-3810. Our answering service will determine whom to contact. You may be requested to visit your local emergency room. You may also be contacted by our staff and/or asked to schedule an appointment during the next business day. Your cooperation is appreciated

      Patient’s Signature                                                                                    Date