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CHARLES E. BURDA, M.D. & ADVANCED BEHAVIORAL CENTERS OF DUPAGE
Terrace Executive Center
1 S. 376 Summit Ave., Court D, Unit 5B
Oakbrook Terrace, IL 60181
Dr. Burda: (630) 629-2700
Physicians: (630) 629-6550
FAX: (630) 629-6558
Hinsdale Professional Office Center
501 W. Ogden Ave., Suite 1
Hinsdale, IL 60521
Therapists: (630) 986-0599
Fax: (630) 986-1477
OFFICE AND FINANCIAL POLICIES
Thank you for choosing Charles E. Burda, M.D. & Advanced Behavioral Centers of Dupage, LLC for your
treatment needs. The following is a statement of our Financial & Office policies that we require you to read and
sign prior to any treatment.
PATIENT CHECK IN/CHECK OUT
All patients, whether you are new to the practice or an established patient, must check in with the receptionist at
the time of an appointment with one of our providers. You may be asked if any of your demographic
information has changed and you may be asked to show your insurance card at every visit. You will be asked to
pay your co-insurance and any balance on your account at the time of checking in. If you do not have your copayment available at the time of service, a $10.00 processing fee will be charged to your account for us to send
you a statement in the mail.
After your appointment, please check-out with the receptionist. You will schedule your follow-up visit with
your physician at this time. Non-physician providers may schedule their own follow-up visits with clients.
INSURANCE PLANS ACCEPTED
Most members covered under POS (point of service) or PPO (preferred provider organization) plans are
required to make some type of payment for services rendered. This may be in the form of a co-payment,
deductible, or coinsurance. If your plan has a co-payment, you will be expected to pay this amount prior to
being seen by the clinician. If your provider participates in your insurance plan, he/she is required under their
contract to collect co-payments, deductibles, and coinsurance payments from you.
FOR PATIENTS NOT UTILIZING ANY INSURANCE OR FOR PATIENTS SEEING AN OUT OF
NETWORK PROVIDER
You will need to pay the entire charge at the time of service. We will be happy to provide you with a receipt
that you may submit to your insurance company for reimbursement. A discounted rate will ONLY be given to
those patients WHO WILL NOT be requesting a statement to send to their insurance company.
BALANCES ON ACCOUNT
All previous balances are to be paid in full prior to additional services being rendered. We request that you
keep a current credit card on file with us so that your balance can be paid at each time of service. Once we
submit a claim to the insurance company on your behalf, they will determine what your financial responsibility
for a particular service will be. Often, this process takes several weeks. We request your permission to charge
your credit card for your portion of the bill once your insurance company has determined your financial
obligation.
Any outstanding balance will need to be paid in full in order for a client to continue seeing their doctor or
therapist. If payment cannot be paid in full at one time, then you will need to contract our billing office to
arrange a payment plan.
NON-COVERED SERVICES
Returned Checks
Checks returned for nonsufficient funds will incur a $40.00 service fee to be added to your account balance.
If you should have a check returned to us for non-sufficient funds, we will require you to pay for services by
cash or credit card for subsequent services.
Cancellation/no-shows
You must notify our office at least 24 hours prior to your scheduled appointment if you intend to cancel.
Patients who fail to notify us of their intent to cancel or who fail to keep a scheduled appointment will be
charged $60 if no notification is given and $30 if notification is given less than 24 hours before the
appointment.
Phone calls to providers/Phone calls on behalf of patients
In general, the physicians are available to speak to patients outside of business hours if a patient is having a side
effect of a medication and needs to talk with a physician urgently. However, there are times when a client is in
distress and just wants support. We strongly suggest that if you are experiencing psychological distress that is
not related to an imminent medication reaction or health risk, that you schedule an appointment with your
physician or therapist to be seen as soon as possible. Your concerns can be better addressed in the context of a
professional session with your behavioral health provider.
For this reason, we discourage any phone calls in excess of 15 minute and have therefore implemented the
following fee schedule for any calls that exceed 15 minutes below:
Any phone call to a provider which lasts 15 minutes or longer will be charged at the following rates:
Masters’ level therapist (e.g., LCPC, LCSW): $40 per 15 min. increment
Psychologist (e.g., Ph.D., Psy.D.): $50 per 15 min. increment
Physician (e.g., M.D., D.O.): $60 per 15 min. increment
Sometimes phone calls may be made on your behalf or on behalf of your child (e.g. to a school representative,
to a health care provider, to an attorney) regarding your treatment or the treatment of your child. Treatment
coordination with these collateral sources are usually not reimbursable by insurance and will be billed to the
patient or patient’s guarantor at the rate indicated above.
GROUNDS FOR TERMINATION OF SERVICES
If you fail to give us 24 hours’ notice of cancellation or miss an appointment on three separate occasions, we
reserve the right to discontinue your treatment with your doctor or clinician. If you fail to stay current on any
outstanding balances, we also reserve the right to discontinue your treatment at our Centers. We will provide
you with referrals to other providers in your area if you should wish to continue services.
AFTER HOURS AND EMERGENCY ACCESS
If you have a life-threatening medical emergency, please call 911 immediately or go to the nearest emergency
room. All non-urgent issues should be addressed by calling 630-986-0599 during regular business hours. The
expectation is that your provider will be able to respond to these non-urgent messages within one business day.
PRESCRIPTION REFILL POLICY
Please allow us 48 hours to fill your prescription refill request should you call to have your prescription
renewed. Prescriptions will be filled Monday through Friday ONLY. Ideally, you should call when you have
approximately one week left of medication. You may have your pharmacy fax us a prescription refill request or
you may call us to request a hard copy prescription. ALL PATIENTS MUST PICK UP THEIR HARD
COPY PRESCRIPTIONS AT OUR OAK BROOK TERRACE LOCATION:
Terrace Executive Center
1 S. 376 Summit Avenue
Court D, Unit 5B
Oakbrook Terrace, IL 60181
We do not mail prescriptions. Please plan the timing of your prescription requests accordingly.
NARCOTICS/CONTROLLED SUBSTANCES
Prescriptions for controlled substances (e.g.,stimulants) must be picked up in person by the patient or by the
patient’s legal guardian (if patient is a minor). You will have to show proof of identification to pick up a
prescription for a controlled substance as well as signing a form indicating receipt of the drug. We are
required by law to verify the patient’s identity before releasing a prescription for narcotics or controlled
substances.
EMAIL POLICY
Email is a convenient and efficient way to communicate non-urgent questions, requests and messages that you
may have for our office staff or providers. Patients need to understand that the confidentiality of email or
text message exchanges cannot be guaranteed.
If you wish to communicate with your specific behavioral health provider, we strongly encourage each patient
to inform your provider of your request. Your provider will then discuss with you how the two of you will
communicate in a way that utilizes encryption of messages and will come up with a unique password that you
will use in order to decrypt messages sent to you by our providers. Please note that any messages that you send
to us will not be encrypted unless you utilize your own encryption program. Our providers will make every
effort to send you messages using encryption technology that will require you to use a unique password in
order to read the message that will be sent to you.
PRIVACY POLICY
Please download and print our privacy policy from our website (www.abcdupage.com) if you wish to keep a
copy for your records. You may also request a copy at our office during your next visit.
Thank you for reviewing our Financial and Office Policies. Please let us know if you have any questions or
concerns. I have read the Financial & Office Policies and understand and agree to adhere to these policies.
Signature
Last revised 03/17/15
Date