Forms & Fees – chspsych.com

Prior Authorization Requests

Please Note:

Prior authorisations are required when your insurance company requires justification for why you need to take this medication.
Completing a request does not guarantee your insurance company will agree to pay for the medication. I will do my best to advocate for you. Should they deny coverage, your options then would be to pay out of pocket or change medications.
I will need up to date insurance information (including any of the following if you see it on your card: Plan Name/BIN/PCN/Rx Group). This will help ensure the correct form for your specific insurance is completed. If the wrong form is used, the PA would need to be redone and would delay a response.
Insurance companies generally have 5-7 days to reply.
I may need to correspond with you for information regarding previous trials of medications if the insurance company requires.
Please do not text me to let me know you have a prior authorisation request.
If you do not want to wait for a response from your insurance company, you can fill it out of pocket. Some insurances will retroactively reimburse you once a PA is completed. There is an app called GoodRx that will provide coupons to help offset the price.

Name*
First Last
Date of Birth*
Email*
Phone*
Medication and Dosage Requested*
Preferred Pharmacy*
Pharmacy Address*
Street Address Address Line 2 City State ZIP Code
Current Insurance Provider
Current Insurance ID Number
Plan Name/BIN/PCN/Rx Group if is available. Please identify which one(s) you are inputting. You may enter “unknown” if the information is not available.
Refill Request Confirmation*
I understand prior authorisation requests may take 5-7 business days and completion of a request by Dr. Sood is not a guarantee that my insurance will cover this medication.
- Yes

Neuroleptic Consent Form

Neuroleptic (Antipsychotic) Medication Consent Form
Patient Name(Required)
First Last
Decision Maker Email(Required)
Date(Required)
MM slash DD slash YYYY
Consent(Required)
I understand that neuroleptic medications (antipsychotics) may be helpful in treating my medical condition. Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, Abilify, and Invega are examples of newer neuroleptics. Haldol, Prolixin, and Navane are examples of older neuroleptics.

These medicines may help me think more clearly, feel less aggressive and hostile, and may decrease other psychiatric symptoms. Some of them may decrease other psychiatric symptoms. Some of them may help my mood. If I take these medicines regularly, they may keep my symptoms from coming back. The medical staff cannot guarantee how I will respond to these medications.

I have talked with my doctor or nurse practitioner about common side effects with these medications. We have talked about tardive dyskinesia (TD). I have been told TD describes movements of the mouth, jaw, tongue, hands, feet, or body that may be irreversible. I know if happens most often when you take older medicines for a long time, and that it can occur spontaneously even when someone has never taken these medications. The newer neuroleptics can cause it too, but much more rarely than the older medications. Sometimes it appears after medicine is stopped or decreased. I have been advised by my doctor to report any symptoms of TD, or other problems related t taking my medications as soon as possible.

My doctor and I have also discussed these medications my cause my blood sugar and/or cholesterol levels to go up. I have been told that while taking these medications I may need to be monitored for these side effects, including blood testing.

My doctor and I have talked about different treatments for my symptoms and we agree that neuroleptic medicines may help by illness. I have been told that without this medication my condition may improve very slowly but is likely to get worse.

My doctor will try to answer questions I have about these medications. We will work together if we need to change the dose/change medications/stop medications. I agree to take the medications as prescribed by my doctor for the treatment of my medical condition.
I agree to I agree to Neuroleptic Medication policy

Downloadable Forms

Downloadable Complete Packet
Patient Registration Packet (Full)

Downloadable Individual Forms
Registration Sheet

Consent for Treatment

Confidentiality Statement

Neuroleptic Consent Form

Insurance Accepted

I do take most commercial insurances, as well as Medicare and Medicaid. It is your responsibility to ensure I am within network with your insurance.

For commercial insurances, it is also your responsibility to see what your yearly deductible is and if you have met it. If you have not met your yearly deductible, then visits are out of pocket until deductible is met. My biller will apply it to your insurance.

Out of pocket fees

Initial Psychiatric Evaluation: $350

Follow up appointments/Medication Management: $125

Individual therapy: $350/hour

Second Opinion/One time consult: $500

I accept cash, check, and credit card.

Cancellation Policy

I will generally text reminders of appointments 1-2 days prior to your appointment. You will also receive an email reminder about 1 week before the appointment from my medical records system (It will come from “PatientFusion”)

Appointments that are not cancelled within 24 hours prior to appointment or missed (barring special situations) will be charged the full out of pocket charge. Insurance does not apply to this situation.

Make a Payment

Online

If you have received a bill for balances due after copayment and insurance payment, you may pay the balance online at myproviderlink.com

Click on “Guest Pay” and enter your account number shown on the top left of your payment statement.
The form ID needed is 22032162

Pay by Mail

If you wish to mail a check, please contact Dr. Sood for an address

NOTE: Please make checks payable to CHS PSYCHIATRIC ASSOCIATES

Billing Questions

If you have billing questions, please call 843-620-3770 or email sood@patientbill.net

Forms and Fees

Prior Authorization Requests

Prior Authorization Requests

Neuroleptic Consent Form

Neuroleptic (Antipsychotic) Medication Consent Form

Downloadable Forms

Downloadable Forms

Fees for Treatment

Fees for Treatment

Insurance Accepted

Out of pocket fees

Cancellation Policy

Make a Payment

Make a Payment

Online

Pay by Mail

Billing Questions