Patient Consent Form

Patient Agreement

General consent. The undersigned individual is voluntarily seeking healthcare services at New Brain Frontier LLC and is free to leave at any time. New Brain Frontier LLC reserves the add/discontinue any service upon giving 30-day written notice (Email:

Payment. New Brain Frontier LLC is a direct pay practice. It is our commitment to keep all fees transparent. Credit card information is kept on file in order to reserve your appointment time online. Your credit card will not be charged except in the case of no-show and no notice within 48 hours. Payment is made at the time of service in the form of cash, debit/credit card, or FSA/HSA cards.

Time Increment. Billing begins when the doctor walks from his or her clinic office to the exam room (enters start time), where the patient will be waiting, and ends when the doctor returns to his or her clinic office (enters end time). Patient will be notified 5 minutes prior to the end of the reserved appointment. Appointments that exceed the scheduled end time by 5 minutes will be charged the next level of service.

Cancellation. Appointments cancelled without a 48-hour notice are charged a $75 fee.

Non-participation in insurance. New Brain Frontier LLC does not contract with any health insurance plan, and will not bill insurance carriers. Each patient is responsible for the payment of all charges, deductibles, and copays. Some services may be reimbursable by private insurance plan or HSA; it is patient's responsibility to verify this.

Medicare program. This office does not participate in the Medicare/Medicaid programs. The patient might be able file a claim for any Medicare benefits, but not Medicaid.

Availability. Staff may be unavailable at times due to illness, technical malfunctions, or other unforeseen situations. New Brain Frontier will attempt to arrange coverage but this is not guaranteed.

Communications. Please call the office only during business hours. If you have a medical emergency, please call 911 or go to the closest emergency room. You may leave a voice message or email and we will get back to you during our business hours. (Due to time constraints, phone calls of any length covering new symptoms will require an appointment.)

By signing up, I certify that I fully understand the above policies and consent to treatment.