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Policies

Learn about all of our practice policies, from appointments to phone calls

Divorced parents with joint custody must provide a copy of the custody agreement for new patients noting which parent has medical decision-making authority.

Policy revisions are designed to enhance the quality of care, improve patient-provider engagement, and maintain compliance with current healthcare regulations. Impireum remains committed to accommodating all patients while ensuring safe, effective, and compassionate care.

 

Update History: 

October 2025 – Transition to In-Person Care Model

Appointment Policy

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Payment and Fees Policy

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Pharmacy and Medication Management Policy

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Phone Call Policy

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Records and Forms Request Policy

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Specialized Therapy Policy

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Telehealth Policy

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Treatment and Privacy Policies

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APPOINTMENT POLICY CONSENT FORM

At Impireum®, we are committed to providing high-quality care and ensuring fair access to healthcare services for all patients. To maintain efficiency and respect the time of both our patients and providers, please review and consent to the following appointment and cancellation policies:

General Appointment Policy

  1. This policy applies to all services provided at Impireum, including specialized treatments such as Neurofeedback and TMS therapy.
  2. Patients are not allowed to double-book appointments within the same week. If double-booked appointments are identified, both will be removed from the scheduler.

I. Pre-Appointment Check-In Policy

To ensure efficient and timely care, all patients must complete a pre-appointment check-in process 48 hours prior to their scheduled appointment.

A. Requirements:

  1. Complete the online self-check-in via the patient portal.
  2. Maintain a valid credit card on file for payment processing.
  3. Ensure all consent forms are signed and up-to-date.
B. Consequences of Incomplete Check-In:
  1. Appointments will be automatically canceled if the check-in process is not completed 48 hours in advance.
  2. Patients may reschedule through the patient portal or by contacting our office at 346-361-0100.

II. Cancellation and No-Show Policy

A. Psychiatry and Psychotherapy Appointments:

  1. Cancellations made less than 48 hours in advance or failure to attend an appointment will be treated as a late cancellation or No-Show.
  2. Fees for late cancellations or No-Shows:
  • Psychiatry: Member – $175.00; Non-Member – $200
  • Psychotherapy: Member – $149.00; Non-Member – $155.00

III. Waiver Policy

  1. No-Show fee will be waived per patient every 12 months.
  2. Patients who accrue (3) no-show appointments within a 12-month period will be charged the above fees and may receive a discharge letter from the practice.

IV. Same-Day No-Show Fee Policy

  1. Patients who fail to attend their scheduled appointment without providing at least 24 hours’ notice will be charged a same-day No-Show fee:
    • Psychiatry: $175.00
    • Therapy: $150.00
  2. Waiver Policy:
    • One same-day No-Show fee will be waived per patient every 12 months.
    • Patients who accrue (3) no-show appointments within a 12-month period will be charged the above fees and may receive a discharge letter from the practice.

V. Missed Appointment Limits:

  1. Patients who accrue (3) no-show appointments within a 12-month period will be charged the above fees and may receive a discharge letter from the practice.

VI. Courtesy Reminders

Our appointment system sends several reminder notifications before all appointments. However, it remains the patient’s responsibility to attend or cancel appointments in a timely manner.

VII. Purpose of Policies

A. These policies are in place to:

  • Ensure fair access to healthcare services for all patients.
  • Minimize disruptions caused by No-Shows and late cancellations.
  • Respect the time of our providers and other patients.

Questions and Contact

We appreciate you choosing Impireum for your mental health care. If you have any questions regarding this payment policy or need further assistance, please contact us at 877-631-0010 or visit our website at www.impireum.com.

Thank you for trusting us with your care needs.

Impireum®
Your Partner in Mental Health Care

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Book Appointment

Payment Policy for Impireum®

At Impireum®, we are committed to providing accessible and high-quality mental health services. To ensure transparency, please review our payment policy regarding insurance and self- pay services:

I. Insurance Policy

We proudly accept PPO and Managed Care HMO plans for Psychiatry (medication management) and insurance-approved TMS Therapy services ONLY.

Accepted insurance providers include:

  • Aetna
  • Blue Cross Blue Shield (BCBS)
  • Cigna
  • UnitedHealthcare (UHC)
  • Humana
  • Medicare
  • Tricare
  • VA/Triwest

II. Insurance Verification

As a courtesy, we verify your benefits with your insurance company. However, a quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan. If your claim processes differently than the benefits quoted, it is your responsibility to contact your insurance carrier for clarification.

III. Payment Responsibilities

  1. Payment for deductibles, copays, and/or coinsurance is due at the time of check- in unless prior financial arrangements have been made.
  2. If the amount collected at check-in is incorrect, any outstanding balances will be billed and charged. If there is a credit, you will be refunded promptly.
  3. Please note that being referred to our clinic by another physician does not guarantee insurance coverage for our services.

IV. Patient Responsibility

You are 100% responsible for all charges incurred. Verification of benefits or a physician’s referral does not guarantee payment.

V. Contacting Your Insurance

We highly recommend that you contact your insurance carrier to understand your coverage for behavioral/mental health services. Do not assume you will not owe anything if you have multiple insurance policies.

Self-Pay Policy

We offer the following services on a self-pay* basis only:

I. Therapeutic Counseling:

  1. Individual Therapy:
    Initial Session: Members – $207; Non-Members – $220
  2. Follow-up Sessions: Members – $149; Non-Members – $155
  3. Initial Family/Couple Therapy: Members – $247; Non-Members – $260
  4. Follow-up Family/Couple Therapy: Members – $207; Non-Members – $220
  5. Group Therapy: $600.00 per 10-week program

II. Neurofeedback:

  1. Initial Brain Mapping: Members – $507; Non-Members – $575

  2. Neurofeedback Sessions: Members – $147; Non-Members – $157per session

III. ADHD Testing (QBTech):

  1. $250/Per Test

* Note: At your request, the practice can provide you with a detailed CMS 1500 medical receipt, also known as a superbill, to submit to your insurance company for reimbursement. As always, you are encouraged to check with your insurance carrier directly to inquire about what is covered under your specific plan.

Payment Methods

We accept the following payment methods:

  • American Express
  • Mastercard
  • VISA
  • Discover
  • Google Pay
  • Apple Pay
  • Bank ACH
  • TuaPay
  • Care Credit
  • Advance Care

Payment Processing

  1. All payments will be processed electronically and made available via the patient portal at www.impireum.com.
  2. No paper invoices will be mailed to

Credit/Debit Card on File

  1. All patients must maintain a valid credit or debit card on
  2. Failure to maintain a valid card on file may result in the cancellation of future appointments.

Authorization

This authorization applies to all payments not covered by your insurance carrier for services provided by Impireum®.

Questions and Contact

We appreciate you choosing Impireum for your care. If you have any questions regarding this payment policy or need further assistance, please contact us at 877-631- 010 or visit our website at www.impireum.com.

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care

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Patient Request Form

Pharmacy and Medication Consent Form

At Impireum®, we are committed to providing safe and effective medication management while adhering to all state and federal regulations. Please carefully review the following policies and guidelines. By signing this form, you acknowledge your understanding and consent to abide by the terms outlined below.

I. Treatment Goals and Agreement

  1. The goal of treatment is to improve your ability to function. Evidence of improved functioning is required for continued treatment.
  2. Medications prescribed, including controlled substances, are tightly regulated due to their high potential for abuse.
  3. Violations of this agreement may pose health risks to yourself or others and will result in the termination of stimulant medication prescription privileges and potentially the termination of services from Impireum®.

II. Assessment Requirements

  1. A recent written report of a psychological, neuropsychological, or psycho-educational test battery may be required before diagnosing ADHD and starting stimulant medication.
  2. The assessment must have been completed within the past 3 years or as an adult (18 years or older) and still be considered current.

III. Agreement Rules

  1. Medication Usage
  1. I agree to take medications as prescribed by Impireum® according to the agreed schedule and instructions.
  2. I will not increase the dose without approval, as doing so may result in the termination of this agreement.
  1. Medication Sources
  1. I will not seek, accept, or use ADD/ADHD medications from any source other than Impireum®.
  2. This includes medications from other providers, family, friends, or illicit drugs.
  1. Communication
  1. I will communicate openly with Impireum clinicians about my symptoms, their effects, medication effectiveness, and any side effects.
  1. Pharmacy Designation
  1. I will fill prescriptions only at the designated pharmacy in my chart.
  2. If I need to change pharmacies, I will notify Impireum with the new pharmacy’s.
  1. Pregnancy Notification
  1. I agree to take medications as prescribed by Impireum® according to the agreed schedule and instructions.
  2. I will not increase the dose without approval, as doing so may result in the termination of this agreement.
  1. Drug Testing
  1. I agree to cooperate with random drug testing.
  2. If results indicate non-compliance, unauthorized substances, or refusal to cooperate, my medication will be stopped, and this agreement terminated.
  1. Medication Security
  1. I am responsible for securing my medications to prevent theft, loss, or access by children.
  1. Law Enforcement Cooperation
  1. Impireum and my pharmacy will cooperate with law enforcement or regulatory agencies in cases of misuse, sale, or diversion of medications.
  1. Lost or Stolen Medications
  1. Early refills will not be provided.
  2. Replacement for lost or stolen medications requires a valid police Multiple incidents may result in termination of this agreement.

IV. Provider Discretion

  1. Impireum is under no obligation to provide medications and reserves the right to discontinue them at any time.
  2. Abusive, violent, or threatening behavior towards staff, patients, or visitors will result in termination of services.

V. Refill Policy

  1. No refills will be provided for missed follow-up appointments.
  2. Patients on controlled substances must attend appointments for refills or adjustments.

VI. Follow-Up Appointments

  1. Patients must be seen at least every three (3) months to remain on a medication management

VII. Specialist Referrals

  1. Impireum may require evaluation by a specialist for co-morbid conditions affecting medication saftey.
  2. I agree to schedule and attend specialist appointments as instructed and authorize communication between Impireum and the specialist.

VIII. Legal Compliance

  1. Obtaining stimulant medications fraudulently, possessing them without a prescription, or giving/selling them to others is a felony and a violation of this agreement.

IX. Authorization

I authorize Impireum® to:

  1. Obtain medication history from pharmacies, health plans, and other healthcare providers.
  2. Share information with pharmacists, other providers, local medical facilities, the Texas Board of Pharmacy, the Texas Department of Public Safety (DPS), the Drug Enforcement Agency (DEA), and the Texas State Board of Medical Examiners (TSBME) as necessary.

Questions and Contact

We appreciate you choosing Impireum for your mental health care. If you have any questions regarding this payment policy or need further assistance, please contact us at 346-361-0100 or visit our website at www.impireum.com.

Thank you for trusting us with your care needs.

Impireum®

Your Partner in Mental Health and Wellness Care

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Request Update

Phone Call Policy Consent Form

At Impireum®, we strive to provide the highest quality care to all our patients. To ensure efficient communication and equitable access to our providers, we have established the following Phone Call Policy. By signing this form, you acknowledge your understanding and agreement to adhere to the policy outlined below.

I. Emergency Situations

If your call is an emergency, please call 911 or go to the nearest emergency room immediately. Our office is not equipped to handle emergency situations via phone.

II. Provider Availability

  1. Limited Availability During Office Hours
  • Our providers are often in session with patients/clients during the day and may not be immediately available to take calls.
  • If you need to contact a provider between appointments, please submit your request via the Patient Clinical Request Form or the Patient Portal, specifying the nature of your call.
  • Providers will respond to messages as soon as Based on the nature of your request, you may be asked to schedule an earlier follow-up appointment.

III. Phone Consultation Charges

  1. Charges for Extended Phone Consultations
  • Phone calls or extended telephone consultations during office hours that would otherwise require an office visit will incur a charge.
  • Fees are determined based on your insurance policy rate, where applicable, or the Impireum self-pay rate of 00 per 5 minutes, with a minimum charge of 25.00 per 5 minutes.

IV. Questions and Contact

We appreciate you choosing Impireum® for your care. If you have any questions regarding this payment policy or need further assistance, please contact us at (877) 631-0010-361-0100 or visit our website at www.impireum.com.

Thank you for trusting us with your care needs.

Impireum®

Your Partner in Mental Health and Physical Wellness Care

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Schedule Appointment

Document Requests Policy Consent Form

At Impireum®, we are committed to providing timely and accurate documentation to support our patients’ needs. To ensure efficiency and fairness, we have established the following Document Requests Policy. By signing this form, you acknowledge your understanding and agreement to comply with the policy outlined below.

For Medical Records Only:

Please click HERE to request an electronic transfer of your medical records (via Fax or EHR) free of charge.

Document Requests Guidelines

  1. Routine Requests
  • Routine school or work excuses are available upon request at the end of your appointment.
  • Records can be pulled and uploaded to the Patient Portal upon your
  1. Processing Time
  • Please allow 3-5 business days to complete document request 
  1. Brief Forms During Appointments
  • If time permits, brief forms (e.g., absentee notes, accommodation letters) requiring less than 5 minutes to complete may be addressed during your scheduled appointment at no additional charge.
  • Notify the front desk at the beginning of your appointment if these forms are required.
  1. Longer Forms and Letters

  • Forms and letters requiring more time will be completed outside of your appointment. Fees are based on the time required to complete the request as follows:

    Simple (less than 5 minutes): No Charge

    Moderate (5-15 minutes): $50.00

    Lengthy (15-30 minutes): $100.00

    Complex (30-60 minutes): $200.00

    Special Complex (over 60 minutes): $200.00/hour

  1. Printing, Faxing, or Mailing Records
  • If records must be printed, faxed, or mailed, a fee of $25 for the first 20 pages and 0.50 for each additional page will apply.

III. Questions and Contact

We appreciate you choosing Impireum® for your care. If you have any questions regarding this policy or need further assistance, please contact us at (877)-631-0010 or visit our website at www.impireum.com.

 

Thank you for trusting us with your care needs.

Impireum®

Your Partner in Mental Health Care

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Request Refill

Specialized Therapy Patient Policy Consent Form

At Impireum®, we are committed to providing safe, evidence-based treatments to support your mental health journey. Please carefully review the following policies and guidelines for Transcranial Magnetic Stimulation (TMS) and Neurofeedback therapies. By signing this form, you acknowledge your understanding and consent to the treatment(s) selected below.

Treatment Selection

I, the undersigned, consent to undergo the following treatment(s):

1. Transcranial Magnetic Stimulation (TMS)

  1. Description: TMS is a non-invasive procedure using magnetic fields to stimulate nerve cells in the brain, aiming to reduce symptoms of depression, anxiety, obsessive-compulsive disorder (OCD), and other mental health conditions.
  2. Procedure: An electromagnetic coil is placed against the scalp to deliver magnetic pulses targeting specific brain areas.

Potential Benefits:

  1. Reduction in symptoms of depression, anxiety, and OCD
  2. Long-lasting effects on brain function and mental health
  3. Minimal side effects compared to medicationv

Potential Risks:

  1. Temporary headache or discomfort during or after treatment.
  2. Tingling, spasms, or twitching of facial muscles.
  3. Rare risk of seizure (less than 1 in 30,000 treatments).
  4. Temporary hearing changes due to the clicking sound of magnetic pulses.

2. Neurofeedback

  1. Description: Neurofeedback is a non-invasive therapy that uses real-time brain activity displays to teach self-regulation of brain Electrodes are placed on the scalp to measure brainwave activity, which is displayed on a screen to guide exercises for improving brain function.

Potential Benefits:

  1. Reduction in symptoms of ADHD, anxiety, and depression.
  2. Improved focus, concentration, and cognitive function.
  3. Long-lasting effects on brain function and mental health.

Potential Risks:

  1. Temporary headache or discomfort during or after treatment.
  2. Feelings of fatigue or drowsiness.
  3. Rare risk of increased anxiety or emotional distress during the learning process.

3. Treatment Duration and Frequency

Ǫuestions and Contact

We appreciate you choosing Impireum Psychiatric Group for your mental health care. If you have any questions regarding this payment policy or need further assistance, please contact us at 877-631-0010 or visit our website at www.impireum.com.

Thank you for trusting us with your mental health care needs.

Impireum®

Your Partner in Mental Health Care

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Provider Call Request

Telehealth/Telemedicine Consent Form

At Impireum®, we provide accessible and convenient mental health care through our telehealth/telemedicine services. Please carefully review the following policies and guidelines. By signing this form, you acknowledge your understanding and consent to participate in telemedicine services.

I. Emergency Situations

1. Limited Availability During Office Hours:

  • Phone calls or extended telephone consultations during office hours that would otherwise require an office visit will incur a charge.
  • Fees are determined based on your insurance policy rate, where applicable, or the Impireum self-pay rate of 00 per 5 minutes∗∗,with aminimum charge of 25.00 per 5 minutes,

Ǫuestions and Contact

We appreciate you choosing Impireum Psychiatric Group for your mental health care. If you have any questions regarding this payment policy or need further assistance, please contact us at 877-631-0010 or visit our website at www.impireum.com.

Thank you for trusting us with your mental health care needs.

Impireum®

Your Partner in Mental Health Care

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Provider Call Request