We do not offer General Psychiatry Services, commonly known as Talk Therapy, or Medication Management.

Guarantor Form

Nashville NeuroCare Therapy – Guarantor Form
  • Guarantor Information:

    Complete only if the patient is NOT paying for the bill.
  • I, regardless of any insurance coverage, am financially responsible for all charges generated for this patient. Office policy requires payment at the time of service. I understand that unpaid balances over 30 days may be subject to a late fee. I understand that unpaid balances over 90 days past due may be referred to a collection agency.
  • By agreeing to communicate via email, you are assuming a certain degree of risk of breach of privacy beyond that inherent in other modes of traditional communication (such as phone, written, or face-to-face). We cannot ensure the confidentiality of our electronic communications against purposeful or accidental network interception. Due to this inherent vulnerability, we will save email correspondence with you and these communications should be considered part of the medical record; therefore, you should consider that electronic communications may not be confidential and will be included in your medical chart. Never send emails or an urgent or emergent nature and please contact the office if you have not received a reply within 24 hours.
  • Patients are not obligated to continue treatment. If you decide to terminate at any time, you are encouraged to discuss your decision to terminate care with your doctor.
  • I have read the policies listed in this form and I understand and agree to them. I agree to be treated by W. Scott West, M.D., and when necessary, andy doctors covering in his absence. I agree that I am responsible for all charges for services rendered and I agree to the payment policies. I hereby authorize payment by my insurance company directly to W. Scott West, M.D. I hereby authorize my individual provider to release to my insurance company any and all information they may require concerning patient care.
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  • Please check the box so we know you're a real person.
  • This field is for validation purposes and should be left unchanged.

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