SHIELD Psychiatry Concierge Payment & Financial Responsibility Policy

Thank you for choosing SHIELD Psychiatry PLLC for your care. As a concierge practice, services are provided on a direct-pay basis and are not billed to insurance. Please review the following policies carefully to ensure a clear understanding of our financial procedures and expectations.

1. Payment Method and Authorization

To maintain your concierge membership and appointment reservations, a valid credit or debit card must be securely stored on file through our HIPAA- and PCI-compliant PracticeQ (IntakeQ) system prior to your first appointment. Your card will be charged automatically in accordance with this agreement.

  • By signing this agreement, you authorize SHIELD Psychiatry PLLC to charge your card for all scheduled sessions, concierge fees, and additional professional services rendered.
  • Session fees are due in full 24 hours prior to the scheduled appointment unless other written arrangements have been approved.
  • If a valid payment method is not available, your appointment may be released or rescheduled.

2. Cancellation, Rescheduling, and Missed Appointments

Because appointment times are reserved exclusively for you, the following policies apply:

  • Cancellations or reschedules made at least 48 hours in advance will not incur a fee.
  • Cancellations made with less than 24 hours’ notice will incur a $100 late cancellation fee.
  • Missed appointments (no-shows) without any notice will be charged the full session rate.

Frequent cancellations or missed sessions may result in discontinuation of concierge services.

3. Additional Professional Services

  • Extended consultations, report preparation, school or provider coordination, or phone/video communications exceeding 15 minutes are billed at a prorated rate of $250 per hour (in 15-minute increments).
  • If legal involvement requires clinician participation (e.g., records, depositions, court appearances), the professional rate is $750 per hour with a two-hour minimum, payable in advance.

4. Financial Responsibility and Authorization

  • You confirm you are the authorized cardholder for the payment method on file.
  • All SHIELD Psychiatry PLLC services are self-pay only and not submitted to insurance.
  • You agree to maintain an active payment method and to promptly update expired or invalid card information.
  • In the event of a declined payment or outstanding balance, a rebilling or administrative fee may be assessed in accordance with Florida law. Unresolved balances may be referred to collections, and all related legal or administrative costs will be your responsibility.

5. Parent or Guardian Authorization

If services are provided to a minor, the parent or guardian completing this form is financially responsible for all related fees.

Child’s Name:

A copy of this agreement will remain accessible through your secure client portal. By signing electronically, you acknowledge that you have read, understood, and agree to these payment and financial responsibility terms.

Credit Card Form

Concierge Psychiatry at SHIELD

Our concierge model provides personalized psychiatric care for children, adolescents, and young adults, emphasizing privacy, family collaboration, and direct access to your provider.

Membership: $150/month (includes messaging, coordination, and brief check-ins).

Services & Pricing

Initial Psychiatric Evaluation $750 75–90 min

  • Comprehensive diagnostic interview, developmental & safety assessment.
  • Includes QbCheck™ ADHD screening when indicated.
  • Includes first 30-minute follow-up (no extra charge).

Medication Management $250 30 min

  • Focused medication review, side-effect monitoring, and adjustment.

Medication + Therapy Session $395 60 min

  • Combination visit using CBT and supportive therapy strategies.

Parent Coaching / Psychoeducation $250–300 50 min

  • Parent-focused sessions addressing behavior, communication, and family wellness.

QbCheck™ ADHD Test

  • Members: $175 (integrated into plan)
  • Non-Members: $350 (standalone, report sent to PCP)

Concierge Membership Policy

  • Billing: Auto-drafted on the 1st of each month via secure payment on file.
  • Start Date: Membership begins the day of your initial evaluation or onboarding payment.
  • Cancellation: Requires 30 days’ written notice. Fees are non-refundable once billed.
  • Failed Payments: Retried within 48 hours → $25 fee if unresolved. Services paused until balance clears.
  • Termination: Two consecutive failed payments or delinquency may result in account closure.
  • Re-Enrollment: Requires clinical approval and updated payment method.
  • Communication: Secure messaging available for non-urgent coordination; replies within two business days.

Good Faith Estimate Notice

Under the No Surprises Act, all self-pay clients are entitled to a written Good Faith Estimate of expected service costs. Actual costs vary by clinical need and frequency of follow-up.

Written estimates are available upon request. Please email info@ShieldPsychiatry.org to request yours.

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