Genesis Counseling Center P.C

Genesis Counseling Center P.C. Kelly Chun, M.D., FAPA 372 McLaws Circle Suite 1 Williamsburg, Virginia 23185 (757) 253-7651

TREATMENT CONTRACT

Date: _____ / _____ / ______

I, ______understand that continuing my treatment with Dr. Chun (Patient Name) is contingent upon agreeing to adhere to the following criteria:

1. I agree to keep scheduled appointments and be on time.

2. I agree to take medications only as prescribed. The benefits and risks including side effects have been explained to me and all of my questions have been answered to my satisfaction.

3. I agree to abstain from all alcohol and recreational drug use. If I have not abstained, I will inform Dr. Chun of my usage. A random urine drug-screening test may be required at any time. The dangers of mixing prescribed medication and other substances have been explained to me.

4. I understand that I will be billed a fee of $50 for appointments not canceled within 24 hours before the scheduled time. If the office is closed, voicemail is available to give notice of cancellation. I am responsible for remembering my appointment. “THIS IS NOT PAID BY INSURANCE.”

5. I understand there is fee of $25 for any prescriptions called in to the pharmacy or picked up at the office whether routine, lost or because of a cancelled/no show appointment. Refills are handled only during office hours. No refills will be called in without an appointment. “THIS IS NOT PAID BY INSURANCE.”

6. Release of medical records will incur a $25.00 base cost and .50 cents a page. “THIS IS NOT PAID BY INSURANCE.”

7. I understand that my payment is due at the time services are rendered.

8. I understand that Dr. Chun may choose to close my chart if she decides my non-compliance with her treatment recommendation interferes with my treatment or the issues are out of the scope of her practice.

Please discuss any questions or concerns with Dr. Chun. Thank you.

Signature: ______Date: _____ / _____ /_____ (Patient)

Signature: ______Date: _____ / _____ / ____ Kelly Chun, M.D. 1