Fees:

- Initial evaluation: $500

- Follow-up visit: $250

- Crisis/urgent follow-up visit: $350

- Insurance/disability paperwork: $50

If I accept your insurance, fees for appointments may be different, and you will only be responsible for the copay, coinsurance and deductible unless you miss an appointment (see below).

Payment:

Fees are subject to change without notice. Full payment is due at the time of service. Cash, credit and debit cards are accepted. Checks are accepted after the first appointment; a $50 fee will be charged for any returned check.

Insurance is considered a method of reimbursing you for services and is not a substitute for payment. You are responsible for any deductible, coinsurance, or balance not paid by your insurance. As a courtesy, we typically submit claims on your behalf, except when:

- You prefer to submit them yourself

- You have Medicare

- You carry two insurance policies

- Your insurance company rejects our claim

In these cases, you must pay the negotiated insurance rate in full at each appointment.

By signing below, you authorize the release of any medical information necessary to process insurance claims. Balances not paid within two months may result in discharge from the practice and/or referral to collections.

Cancellations and missed appointments:

Cancellations must be made at least one full business day in advance, or you will be charged for the missed appointment. Insurance will not cover missed appointments. Exceptions will be made only for true emergencies. Repeated cancellations or unpaid balances for missed appointments may lead to discharge from the practice.

Telemedicine appointments:

You must be physically located within the state of California or Texas during your appointment. Appointments cannot be conducted while driving, shopping, or engaged in other activities. Both audio and video are required. Phone-only (audio-only) visits are not permitted.

Use of ambient AI for documentation:

During appointments, I use a software tool to assist with medical documentation. This tool helps me focus more fully on your care by converting our conversation into a summary that I will review and edit. The tool will have temporary access to the audio during our session, but the recording will not be saved or reused. Your medical information remains private and will only be shared with those you authorize.

Phone calls:

Please provide a reliable phone number. Calls should be limited to serious side effects or specific follow-up needs. I will make every effort to return calls within one business day. Texting and email are not used. You may schedule, cancel, or reschedule appointments online at www.jasonwinstonmd.com.

Prescriptions:

I aim to ensure you have enough medication to last until your next scheduled appointment. If you run out early, please have your pharmacy send a refill request. Refills will not be authorized without a scheduled appointment.

Discontinuation of treatment:

I will discontinue treatment with you only after considerable thought and usually for one of the following reasons: 1) you exhibit physical violence, verbal abuse, carry weapons or engage in illegal acts in the office, 2) you refuse to comply with office rules, refuse to comply with treatment recommendations or do not make payment, 3) I have lost contact with you, 4) you have not been seen by me for an appointment in over a year, 5) you abuse medications, 6) you receive care simultaneously from another psychiatrist. You can discontinue with me at any time. I will not be offended if you want to discontinue treatment or change providers.

Emergencies/crises:

For emergencies, call 911 or go to the nearest emergency room. For crisis team services, call 800-854-7771 (Los Angeles County) or 805-652-6727 (Ventura County).

Patient’s rights:

1. All patients have the right to informed consent or refusal of treatment recommendations. This means you will be informed of the most common risks and benefits and have the right to consent or refuse this treatment. The only exception to this is if your refusal of treatment will pose the risk of imminent harm to yourself or others.

2. Patients have the right to amend their medical record. I, as your physician, have the right to deny such a request if I believe that the information in the medical record is accurate, but in that case the patient request must still be added to the medical record.

3. Patients have the right to have reasonable requests for confidential communications accommodated.

4. You can give written authorization for me to disclose your psychiatric information to anyone or any party you choose, and you may revoke the authorization in writing at any time.

5. Patients have the right to receive a written notice of privacy practices.

6. Patients can file a complaint about any violation of the rights listed above with me or with the Secretary of the Department of Health and Human Services, Office of Civil Rights, South United Nations Plaza, Room 322, San Francisco, CA 94102. There will be no prejudice for filing such a complaint. Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information please visit www.tmb.state.tx.us.

Patient’s responsibilities:

1. You are responsible for your financial obligations to the office.

2. You are responsible for following the policies of the office.

3. You are responsible to treat staff and fellow patients in a respectful, cordial manner in which their rights are preserved.

4. You are responsible to provide accurate information about yourself.

5. You are responsible to update me as soon as possible of your new address if you move and of your new telephone number if it changed.

Notice of Privacy Practices