<p>Genesis Counseling Center P.C. Kelly Chun, M.D., FAPA 372 McLaws Circle Suite 1 Williamsburg, Virginia 23185 (757) 253-7651</p><p>TREATMENT CONTRACT</p><p>Date: _____ / _____ / ______</p><p>I, ______understand that continuing my treatment with Dr. Chun (Patient Name) is contingent upon agreeing to adhere to the following criteria:</p><p>1. I agree to keep scheduled appointments and be on time.</p><p>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.</p><p>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.</p><p>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.”</p><p>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.” </p><p>6. Release of medical records will incur a $25.00 base cost and .50 cents a page. “THIS IS NOT PAID BY INSURANCE.”</p><p>7. I understand that my payment is due at the time services are rendered.</p><p>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.</p><p>Please discuss any questions or concerns with Dr. Chun. Thank you.</p><p>Signature: ______Date: _____ / _____ /_____ (Patient)</p><p>Signature: ______Date: _____ / _____ / ____ Kelly Chun, M.D. 1</p>