1. finance
2. personal finance
3. insurance

Greg Melieste, MD
Rossi Davis, Psy.D, LPC, Cht
Alan Korbett, DO
Michael Lederman, LMFT
Tom Anderson, Psychologist
Linda Anderson, LMFT
We would like to take this opportunity to welcome you to Counseling and Psychiatry of Gwinnett, LLC. (CPG).
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ADMINISTRATIVE OFFICE HOURS: CPG’s normal administrative phone hours are Monday—Friday 9:00 am—5:00pm
(closed for calls from 12:30—1:30pm). These are the hours for scheduling, rescheduling, cancellations, billing/account questions, medical questions and prescription refill requests. Our voice mail boxes are available 24 hours a day 7 days a week,
however, calls are only returned during administrative office hours
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TREATMENT HOURS: These hours vary by treating provider. You may have appointments scheduled before or after administrative hours depending on the provider you see and the day you are seen.
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INSURANCE: We accept and file most major medical insurance plans. We ask that you provide us with a copy of your insurance card and keep us updated of any changes in your insurance coverage or benefits. INSURANCE: Your insurance policy
is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you
assign the benefits to CPG—in other words, if you agree to have your insurance company pay the doctor directly. We ask that
you contact your insurance company to make yourself aware of your out-patient mental health benefits. If your insurance
company does not pay the practice within a reasonable period, we will have to look to you for help with payment. Any copayment, co-insurance, or deductible amount quoted to you by CPG or your insurance company is just an estimate of your responsibility. All claims filed with insurance companies are subject to benefit and eligibility limitations at the time the claims are
filed. NON-COVERED SERVICES: Any care not paid for by your existing insurance carrier will require payment in full at the
time services are provided or upon notice of insurance claim denial.

REFERRALS AND AUTHORIZATIONS: You are responsible for obtaining any authorization or pre-certification required by
your insurance company for your initial visit with our company. Failure to obtain authorization for services may result in increased cost to your for services provided. Please check with your insurance carrier to find out what if any authorization is
needed.
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PAYMENT FOR SERVICES: **Payment for services rendered is expected at time of service.** This includes copayments, deductibles and co-insurance amounts. WE DO NOT ACCEPT PERSONAL CHECKS. We accept Cash and all major Credit Cards. We do offer a sliding fee scale for patients without insurance. See the front desk for our sliding scale fees.
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APPOINTMENTS: Appointments are held especially for you and they are a valuable resource at our practice. If you are unable to keep your scheduled appointment, please provide a minimum of 1 day advance notice. We charge $25.00 for
missed appointments or same day cancellation of appointments. Fees for missed appointments are due prior to your
next appointment. Appointment reminder calls or emails are attempted as a courtesy for you, but it is your responsibility to keep track of appointment dates and times.

WAITING TIMES: Our providers do their best to see you in a timely manner. If your are more than 15 minutes late for your
appointment, we reserve the right to reschedule you for another time.
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FORMS AND LETTERS: Thank you for understanding that our providers first priority each day must be to see the patients in
the office, therefore, they will complete forms and letters as time permits. Most will be completed within 7—10 business days.
Fees range from $25-$250 per request depending on time required to complete the request.
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MEDICAL RECORDS: The confidentiality of your medical record is our number one priority at CPG. All medical record requests must be in submitted in writing on a CPG medical record release. The Fee for Medical Record Requests starts at
$25.00 and increases with number of pages in the record. Please contact our office for detailed requirements for medical record requests.
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AFTER HOURS CARE/EMERGENCY ACCESS: Our providers have an Answering Service for emergencies that occur after
hours. If you have a psychiatric emergency and cannot wait until the office is open, please call our Answering Service @ 770
-929-6230. Non-emergency calls to the Answering Service may incur a fee. Our voicemail
system is available 24 hours a day 7 days a week. Calls are normally returned during administrative hours.
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PRIMARY CARE PHYSICIAN CONTACT: Most insurance plans require that we communicate diagnosis, treatment frequency, medication, and treating physician to your primary care physician. Please inform us if you do not wish for information
about your visit to be released.
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PRESCRIPTION REFILLS: Please see MEDICATION REFILL POLICY for those seeking medication management services.
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PATIENT RIGHTS AND RESPONSIBILITIES
As a patient of CPG, you have the right to:
1. Receive behavioral health services in accordance with
standards of professional practice.
2. Be treated with dignity and respect.
3. Be treated fairly, regardless of race, religion, gender,
age, disability, or source of payment
4. Have your treatment and other personal information
kept confidential. Only where permitted by law may
records be released without written authorization
5. Easily access to care in a timely fashion
6. Know about your treatment choices, regardless of cost
or benefit coverage
7. Share in developing a treatment plan
8. Receive information in a language you can understand
9. Receive a clear explanation of your condition and treatment options
10. Know their rights and responsibilities in the treatment
process
11. Freely file a complaint or appeal
12. The right to waive any of your rights, if given voluntarily,
knowingly and in competent state of mind.
As a CPG patient, you have the responsibility to:
1. Treat providers with dignity and respect
2. Give providers information that is needed to deliver
quality care and appropriate services
3. Ask questions about your care
4. Follow the treatment plan of care set forth and
agreed upon by you and your provider
5. Follow the agreed upon medication plan
6. Tell the provider about medication changes, including medications being prescribed by other physicians
7. Keep your appointments.
8. Let the provider know when the treatment is not
working.
9. Openly report concerns about quality of care you
receive.
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TERMINATION OF CARE: CPG’s goal is to provide services to patients until the patient and physician/therapist feel
treatment goals have been accomplished. Patients may wish to terminate their care with CPG at any time. Patients
will be considered self terminated if they are out of service for greater than six months. CPG may find it necessary
to terminate the patient/provider relationship for multiple missed appointments, non-payment of account balances, or
inappropriate behavior or conduct toward administrative or clinical staff. CPG will make all notifications of termination
of care in writing.
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SUMMARY OF NOTICE OF PRIVACY PRACTICES (HIPAA): The patient’s health information is private and confidential.
Counseling and Psychiatry of Gwinnett (CPG) works very hard to protect the patient’s privacy and preserve the confidentiality of the
patient’s personal health information. CPG may use and disclose the patient’s personal health information to help provide health
care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no
other uses and disclosures of this information unless the patient permits it. Sometimes the law may require the release of this information without patient permission. These situations are very unusual. Examples would be if a patient threatened to hurt someone or if child abuse is reported. CPG has a detailed document called the “Notice of Privacy Practices”, given to the patient in this
orientation paperwork. It contains more information about the policies and practices protecting the patient’s privacy. Patients have
the right to read the “Notice” before signing any agreement. CPG may update this “Notice of Privacy Practices”. The Privacy Officer or other appropriate administrative employee will provide patients with the most current “Notice of Privacy Practices”. Under
the terms of patient consent, patients may ask CPG to limit how the patient’s personal health information is used or disclosed to
carry out treatment, payment or health care operations. CPG does not have to agree to patient requests. If CPG does agree to
requests, CPG would follow the agreed limits. Requests must be made in writing and CPG will provide a form for this purpose by
request in the office. A patient may cancel the consent in writing at any time by doing one of the following:
(1) Signing and
dating a form that CPG can give me called “Revocation of Consent for Use and Disclosure of Health Care Information”; or (2)
Writing, signing, and dating a letter to CPG. All written letters, must say that the patient wants to revoke their consent to authorize
the use and disclosure of the patient’s personal health information for treatment, payment, and health care operations. If revoked
consent is requested, CPG does not have to provide any further health care services to the patient or may require that the patient
pay directly for any service rendered.
Thank you for taking time to familiarize yourself with our polices and procedures. Please see the receptionist or
your therapist/physician if you have any questions regarding this information.
Your signature on the Acknowledgement of Receipt of Orientation Material line of the patient registration forms demonstrates that you have been notified and are aware of your rights and responsibilities, termination of care situations, and
HIPAA privacy practices.
Counseling and Psychiatry of Gwinnett, LLC
2301 Henry Clower Blvd. Suite A
Snellville, GA 30078
770-978-9393 (Phone)
770-978-9324 (Fax)
www.cpgwinnett.com
REV. 6/2011