December 15, 2022

5 Patient Forms to Establish Your Psychiatry Practice Policies (Downloadable Template)

Written by

Dr. Carlene MacMillan, M.D.

When starting a new practice, you need to have well-documented practice policies, both to set the foundation for a good therapeutic relationship and to protect yourself legally.

In parts one, two, three, and four of this"start your psychiatry private practice series", we covered four questions to ask yourself before starting, budget planning, legal foundations, and finding and furnishing your office.

In this article, we'll guide you through the five policy forms you’ll want to create and send to new patients before their first appointment. Here is a downloadable template to get you started.

Before we begin, download a copy of the Practice Policies Template by clicking on the link above. It offers a rough framework to outline your practice policies as you read. We’ve left these templates open-ended, so you can fill in the details for your unique practice.

1) Patient Information and Professional Service Agreement

The Patient Information and Professional Service Agreement lays out the fundamentals of how your private practice will operate. Some common sections include:

Services Provided

  • What services do you offer and for what purposes?

Length and Frequency of Meetings

  • Include the standard meeting length and frequency for different purposes, such as an initial psychiatric evaluation, psychotherapy appointment, or medication management appointment, either virtually or in person.

Fee Policies

  • In addition to your fees, you’ll want to include how often you plan to raise your fee schedule (such as annually) and a right to increase fees in the future at any time. You’ll also want to explicitly state the services you charge for, and which are considered free. For example, some psychiatrists don't charge for brief phone calls, texts, calls to obtain collateral information, and a review of patient medical history before an appointment.
  • If you take insurance, we recommend including guidance on which services are typically out-of-network.
  • Lastly, you may want to include a note that you will charge for services if your patient becomes involved in legal proceedings that require your participation, and that you reserve the right to determine the appropriate charge based on your involvement.


  • Will you accept cash, check, major credit cards, debit cards, and/or ACH/wire transfers? Please keep in mind that many online payment transfer tools, such as Venmo and PayPal, are not HIPAA-compliant, and thus shouldn't be used for psychiatry practices. Many patients will prefer to pay by credit card, which is also convenient for you because you can store the card information on file and bill after sessions—without needing to track down a payment every time. There are many things you need to consider when choosing a credit card processor, including fees. Choosing a payment service that's already integrated with your EHR may be the most prudent route. Patients who have debit cards associated with a Health Savings Account (HSA) may prefer to pay with a debit card instead.
  • When will you charge patients? We recommend charging patients at the start or end of each appointment so that there’s minimal follow-up on your end to get paid. However, some providers choose to bill patients at different cadences. You'll also want to clearly state when payment is past due.
  • Will you charge a deposit for initial consultations?
  • What is your policy regarding delinquent bills?
  • Would you like patients to contact you first if they suspect credit card fraud or are not satisfied with treatment?


  • Unfortunately, some patients will cancel on you, and you deserve a heads-up because your time is valuable. First, keep in mind that if you take insurance, there may be a predetermined cancellation policy that you have to follow. For your private-pay patients, the policy is up to you. How much notice do you need—24 hours’ notice, 48 hours’ notice, 72 hours’ notice, or more?
  • Will you charge your full rate or a discounted fee?
  • Will you waive your fee if a patient meets certain conditions (e.g., they are able to reschedule to a new time on the same day)? You'll also want to make sure your patients understand that insurance will not reimburse them for cancellation charges.
  • If you have a different policy for group therapy, make sure you include that here as well.

Vacation and Time Away

  • Include guidance regarding practice closures and clinician absences.


  • State which insurance companies you're in-network with, or state if you're out-of-network with all insurance companies. You may wish to include additional details about how patients can obtain out-of-network reimbursement. For example, most EHRs will generate an invoice that you can send to the patient.
  • A high-quality EHR will generate superbills and submit them on behalf of your patients. A superbill is essentially a receipt that shows ICD-10 and CPT codes that patients can submit to their insurance if they have out-of-network benefits. This helps your patients maximize their out-of-network reimbursement benefits and shows patients you’re on their side and want to help them. How often you want to provide superbills to your patients is up to you.

Communication Outside Scheduled Appointments

  • You’ll want to note if patients are free to contact clinician(s) and administrative staff via phone call, email, or text, and which services are free or incur a charge.
  • Note your privacy standards, typical response windows, and what to do in the event of a life-threatening psychiatric or medical emergency (typically go directly to the nearest emergency room or call 911).
  • Also let your patients know what other resources are available to them and how patients can opt out of SMS texts, voicemails, or emails.

Social Media Policy

  • Typically, psychiatrists do not accept requests to connect with patients or their family members on personal social medical accounts. You may want to explicitly state your social media policy, including asking your patients not to contact you through social media, unless you have a pre-existing relationship.
  • Additionally, you'll want to state that you will not respond to personal information in reviews left on professional websites such as Google Reviews or Healthgrades due to confidentiality.

Communication with Other Providers and External Entities

  • Explain your policy around maintaining contact with patients’ other medical providers, including their PCP, relevant specialists, and mental health (prescriber or therapist) providers.
  • Note that you'll provide HIPAA-compliant Release of Information forms for patients to share other providers’ or stakeholders' contact information and provide permission for you to exchange information with them.
  • Additionally, note your policy for providing personal information with outside businesses, such as insurance agencies, credit card processors, and your electronic medical record vendor.


  • Confidence in patient/doctor confidentiality is an essential component of mental health treatment.
  • Your confidentially policies may include how you share information with colleagues, or share information without authorized release, such as in the case of abusive treatment and/or neglect, threat of bodily harm to oneself or others, legal action, care of minors, small claims court, and de-identified and anonymized data for the purposes of conducting research.
  • Additionally, state your policy for accepting information from loved ones or other concerned parties.

Freedom to Withdraw

  • State your right to end treatment at any time, and the policies you commit to following if ending patient treatment.

2) Notice of Privacy Practices

A “Notice of Privacy Practices” describes how protected health information (“PHI”) may be used and disclosed and how you can get access to this information. You’ll want to include:

  • Your pledge stating you are committed to protecting patient health information. And that you reserve the right to change the terms of the notice.
  • How you may use and disclose patient health information.
  • The uses and disclosures of health information that require patient authorization. For example, you may wish to include language about your use of Psychotherapy notes, and that you do not disclose PHI for marketing purposes or sell PHI in the regular course of business.
  • The uses and disclosures of health information that do not require patient authorization. For example, when disclosure is required by law, for public health activities, health oversight activities, judicial and administrative proceedings, law enforcement purposes, coroners and medical examiners, research purposes, and more.
  • The uses and disclosures of health information that give patients the opportunity to object. For example, your policy on disclosures to patient family, friends, or others.
  • Patients’ PHI rights, such as the right to request limits on uses and disclosures of PHI, request restrictions for out-of-pocket expenses, right to choose how to get sent PHI, right to see and obtain copies of their PHI, right to see practice disclosures, right to correct and update PHI, and right to get a paper or electronic copy of this notice.

3) Telehealth Informed Consent

A form that helps your patient understand how your practice uses telehealth, and what they should know before engaging in telehealth treatment. Common sections include:

  • A description of telehealth.
  • The potential benefits of telepsychiatry.
  • The potential risks of telepsychiatry.
  • Patient rights concerning telepsychiatry. For example, letting patients know that all laws protecting the privacy and confidentiality of medical information also apply to telehealth and that both the patient and clinician have the right to withhold or withdraw their consent for the use of telehealth at any time during the course of care.
  • Patient responsibilities, such as stating their physical location at the start of each session with an understanding that a clinician can terminate a session if they join from a location where a psychiatrist is not licensed. They also must have the necessary computer, software, internet, and knowledge for telepsychiatry, and commit to taking steps to troubleshoot if they are disconnected, etc.

4) Fee Agreement and Good Faith Estimate

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers including psychiatrists and therapists are required to notify patients of their federal rights and protections against “surprise billing.”

The purpose of the Act and of this document is to protect patients from unexpected medical bills. It is a federal requirement that each patient signs this form annually to begin/continue treatment. Sections you’ll want to include:

  • An overview of the No Surprises Act, and how your practice adheres to the federal legislation.
  • The fees for each service you offer and time estimates, including for expert consultation and appearances in court. Also, include any notes on your fee schedule such as typical appointment frequency and a patient’s right to determine how long they need treatment.
  • Required disclaimers, including guidance on how patients can get questions about their rights answered, how they can dispute a bill and any applicable fees related to the dispute process.

5) Authorization to Disclose Protected Health Information

This form gives you authorization from a patient to obtain information from, or release information to another party. A patient can indicate what information they are authorizing for release, why the information is needed, and limitations on disclosure. Our provided template is a comprehensive example.


Many of these policy forms involve highly personal practice decisions. The most important thing is that you clearly communicate policies to patients when they make an appointment. We recommend you state these policies on your website, and store consent to these policies in each patient’s medical record.

A quality EHR will let you add custom intake forms to send to patients ahead of time and auto-store the forms in their patient records to simplify your process.

Creating policies sets your legal foundation and protects you and your patient. Feel free to download and save a copy of your Blank Practice Policies Templates; you'll save time with a guided framework to outline your practice policies. We’ve left these templates open-ended, so you can fill in the details that fit your unique practice.

When you're ready to save even more time, Osmind customers gain access to an extensive library of detailed policy templates that are completed with suggested policies.

If you’ve been following along in our “start your practice series,” you’ve now completed what you need to do in order to start seeing patients! In future articles, we’ll talk about marketing your practice, and cultivating a community for continuous learning.

Disclaimer: The information provided here is not intended to provide legal advice, nor is it intended to replace your own research and understanding of regulations implemented by governing bodies. We strongly recommended going to the appropriate regulatory body to make your own interpretation of the requirements, based on your own practice situation. This template is intended only to assist in making it easier to abide by these regulations and it is expected you would make adaptations to this based on your own practice.

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