Patient Agreement


I understand that Dr. Levy is treating me as an integrative/holistic medicine specialist, and is not serving as my primary care physician.

I understand that Dr. Levy does not use a beeper or an answering service – his cell phone number, 716-479-2240 is provided to all patients. Messages on Dr Levy’s cell phone are frequently retrieved, and all messages from patients are responded to within a reasonable time. However, in the event of an emergency, Patient should either contact his/her Primary Care Physician or go directly to an emergency room.  

I understand that Patient is responsible for payment for office visits at the time of service, and that Dr. Levy does not participate with any health insurance plans in his office practice. Office visits may be scheduled for 15 minutes ($50), 30 minutes ($100), 45 minutes ($150), or 60 minutes ($200). Upon request, Dr. Levy will provide an encounter form for Patient to submit to his/her health insurance company.

I understand that Dr. Levy charges at a rate of $200/hour for phone calls, email exchanges (email correspondence requires a signature on an email consent form), prescription refills, and completion of forms. Payment for these services is due within 30 days of receipt of a bill.

I understand that the hourly rate for services may change – Dr. Levy will provide advance notice of any changes in rate.

I understand that there is a charge of $100 for missed appointments, and for appointments which are cancelled with less than one business days’ notice. 

I understand that checks returned for insufficient funds will result in an additional charge to the Patient of $30.

 

Click "Download PDF" button below to print and sign the the Patient Agreement.

OR

Click on Online Patient Agreement to fill out a digital version. The form is secure using HTTPS:// protocol. Once Signed, you will receive a signed version of the Patient Agreement via Email.

Note: After completing the Patient Agreement, call Betsy at (716) 867-4114 to set up an appointment.


Page Updated January 29, 2016