General Policies: 


Welcome to my practice.  A personal chart has been set up for you in our Electronic Health Record,  “DR CHRONO”.  A PORTAL INVITATION is being sent to your personal email address.  Please check your in-box (or possibly spam folder)for the invitation.  Open the invitation and  confirm (1) your date of birth and (2) your phone number to finalize this invitation . Once completed, the PORTAL gateway is activated and you can self-schedule an initial 1 hour appointment.   All future appointments are also self-made through the portal. Canceling  and rescheduling of appointments are made by the same means.

It is IMPORTANT that you always NOTIFY ME at least 48 HOURS IN ADVANCE TO CANCEL AN APPOINTMENT (unless an emergency occurs preventing you from keeping the appointment). Please DO NOT  schedule other outside appointments immediately following your visit with me.  This allows  some flex time if necessary for your visit.   

I DO NOT CHARGE FOR THE FIRST "NO SHOW" OR FOR ONE LAST MINUTE CANCELLATION. However, for those who do not show for a scheduled office visit,or have more than one canceled visit within 24 hours of their appointment, I  require  PRE-PAYMENT prior to your next visit and  BEFORE the next appointment is made. Should the next visit be a No-Show,  canceled less than 24 hours prior, or should you show past your scheduled visit, the PRE-PAYMENT FEE WILL BE FORFEITED.     


Our next available appointment is _______________.   You can check on appointment availability to change to an earlier appointment time if desired, since we occasionally have a cancellation each week. All appointments are scheduled hourly:  Tuesdays and Wednesdays,  10am - 5pm.  I do make myself available outside of hours through the PORTAL for email messaging primarily (or a phone call for true emergencies). 

Once you have made the initial appointment, please electronically sign a HIPAA form on line regarding office privacy policy. Then fill out an electronic QUESTIONNAIRE that will help make your initial appointment more efficient. Questionnaires will be maintained in your electronic health record. 

You may communicate with us between visits through our electronic record PORTAL without charge. Please use the PORTAL when necessary and appropriately; however please avoid daily messaging. Please do not use regular email messaging for transmission of any medical information or requests. This is not legal according to federal HIPAA regulations.   

If you have any urgent or emergency concerns at this point, please let me know by responding to this message. DO NOT EVER USE THE PORTAL TO NOTIFY ME OF ANY TRUE EMERGENCIES.   We will discuss this issue at your initial visit. 

IMPORTANT:  Register for the PORTAL NOW , or as soon as possible. The invitation expires soon if not used. If you do not register, this will delay your mental health care. 

If any initial technical issues occur preventing you from signing up, please let us know as quickly as possible by responding to this message so that we may assist you. I do have an Office Manager , Shawn, who may also contact you to assist in solving sign-up problems.

I encourage new patients to be seen along with close family members to verify initial information.  Please do not bring young children with you to office visits.  This does not work in my office environment. 

Do not attend an office visit if you are acutely ill, coughing, sneezing, vomiting or have fever. I do understand if you need to cancel an appointment at the last minute under such circumstances, or if you have an acutely ill family member at home who has no one else to care for them.  

You may bring a small service animal(dog) with you to your office visits.  

Please remember that payment is due at the time of your visit.  I accept most credit cards, checks with verification, and cash. A superbill is provided so you can obtain reimbursement from your insurance company if eligible.  I  electronically  send in special forms for reimbursement on behalf of Medicare patients.  I am unable to accept straight Medi-cal patients at this time as I am not currently registered to do so.

Please bring in all current insurance cards so that I may keep a copy in your chart. Often the information is needed for an authorization regarding treatment or medication.      

Please bring in any appropriate outside records, lab results, imaging studies such as x-rays or scans, EKG's, pathology reports. 

Bring in a list of ALL your medications, vitamins and over the counter agents you are taking or have taken in the past. The list should include dosages, frequency you are taking the medications, etc, and when a refill will be needed for any current psychiatric medications.  I wish to know which medications have been helpful, which were not, and which may have caused intolerance or allergic reactions.  I am not able to prescribe or refill non-mental health medication.

Detailed or extensive disability forms, or other similar insurance forms may be able to be completed by me. If so, these will result in additional charges based on length and time to complete.  

I will need the name, phone number and complete address (include ZIP code) of a local pharmacy you wish to utilize. Please provide a local pharmacy name even if you have Kaiser insurance. I do have some Vouchers and Savings Cards that can save money.  These are based on individual circumstances and types of insurance. I can assist in helping you find the most economical pharmacies for specific medications.      

I hope this answers most of your concerns. I will ask that you sign a copy of this document for my record and will be given a copy for your records and future reference as well.

Again, welcome and I look forward to our first meeting together. 



Patient Name:____________________ Date of Birth: ______________

SPECIFIC POLICY GUIDELINES:     I have a  number of patients who recurrently cancel visits within 24 hours of their appointment time , or simply do not show up for their scheduled visit.   If I am unable to fill that missed appointment time, the 1 hour appointment slot goes unfilled.  I see only  6-7 patients  in an 8 hour day,  2 days per week.  I routinely send out multiple appointment reminders for every appointment.   Yet, as many as 20-30% of patients still do not show up for their visit or cancel within 24 hours of the allotted time.  When this happens,  I am unable to provide an effective and cost- efficient practice for all those who wish to see me.

 This leaves me with one of two options.  (1)  Raise my current fee schedule for all patients in order to compensate  for this misuse of my time,  or (2) require that all scheduled patients keep their allotted time of visit.  If unable to do so, then simply provide me with adequate notice by portal email messaging. Cancel 48 hours or more prior to the scheduled visit unless a true emergency or an acute illness arises.  Many physicians charge a “missed appointment fee” of  $75- $150 as a “no show” or late cancellation fee.  I do not care for this policy and therefore choose not to do so.   


 This policy is straight forward :  Make an appointment --- keep the appointment -------  or cancel appropriately.   If this does not happen,  then  PRE-PAYMENT WILL BE REQUIRED  BEFORE RECEIVING A CONFIRMED  FOLLOWUP VISIT.  

 Each  patient or family  may receive one excused late cancellation (less than 48 hours)  but will not receive an excused  "NO SHOW"   before the policy goes into effect for themselves.   Extenuating circumstances will gladly be  reviewed based on patient request.       

 When  PRE-PAYMENT IS REQUIRED,  I ask that you prepay by credit card,  check or cash for your next visit , PRIOR TO A CONFIRMED SCHEDULING.  This also applies to NEW patients who miss their initial visit.  When you keep future appointments appropriately, I typically drop this policy and return to “pay as you are seen.”

 Please be aware that if you are not being followed on a regular basis, as appropriate for age, condition and severity,  then I will not continue providing  long term care or  ongoing medication refills beyond 6 weeks.  I will request your input as to whether you wish to continue under my care and abide by this policy.      

I do make an effort to fill  missed or late-canceled appointment times.  If I am able to fill the “empty” time slot,  then your PRE-PAYMENT FEE will NOT be forfeited. I will notify you of the outcome of the  appointment in question.  

Remember, this fee is NOT  an additional  charge to the cost of  your office visit. It is your guarantee that you are serious about making and keeping your appointment that you self-scheduled.  You are credited your fee upon completing the office visit.   You forfeit this fee only if you do not keep your appointment or cancel your visit inappropriately.  You CANNOT  bill insurance for reimbursement of a forfeited office visit.

 You are more than welcome to request information or discuss concerns about this policy.  In order to continue under my care,  I do ask that you sign this letter as your agreement and acceptance of these terms.  Thank you.

 ___________________________________ Date: _________________

Patient Signature

___________________________________  Date: _________________

Jeffrey Applebaum, MD