Westlake Psychiatry

Conditions of Service

Westlake Psychiatry, PA (herein "Westlake Psychiatry")— Service Agreement & Payment Authorization

Conditions of Service Agreement:

Cancellation & Missed Appointments – My appointment is reserved exclusively for me. I will call the office to cancel or modify. I agree to pay the full cost of any scheduled appointment unless it is canceled at least TWO FULL BUSINESS DAYS in advance (Mon–Fri, holidays excluded).
Emergencies – The office is open by appointment only and provides no on-call services. For any emergency I will dial 911 or go to the nearest emergency department.
Telehealth, Electronic Communication, Technology, & Medical Records – Sessions must take place in a private setting and will not be recorded. E-mail or text is courtesy only; I will call or schedule for substantive matters. I consent to Westlake Psychiatry’s good-faith use of current and future technologies for facilitation of care, scheduling, communication, and record-keeping. I accept the inherent risks of electronic systems and agree that I will not hold Westlake Psychiatry or it's owners, staff and clinicians liable for breaches, mis-deliveries, or errors. I acknowledge and understand that Westlake Psychiatry is not considered a HIPAA covered entity. Texas Privacy Law and our steadfast commitment to your privacy are foundational to our services and we endeavor in good faith to always ensure the dignity and privacy of our patients. The practice complies with Texas Health & Safety Code § 181 and may use HIPAA-compatible tools that meet or exceed state standards. Westlake Psychiatry operates as a fee-for-service practice and does not bill insurance or coordinate benefits electronically.
Session Time, Documentation, Extra Time & Collaborative Work – Sessions are timed. I acknowledge and accept that any professional time beyond the scheduled session—whether at my request or at Westlake Psychiatry’s discretion in good-faith pursuit of quality care—is billed in additional 15-minute blocks at the same rate. I accept that all time spent coordinating with outside parties, preparing paperwork or medical records, or handling legal matters is to be billed and paid in advance in the 15 minute increment manner of the current or previous clinical provider at the clinician's current rates with the exception of legal involvement, which I accept includes the prepayment of four billable hours regardless of cause or subpoena. I will provide a card on file for these purposes as stipulated below.
Payment & Card on File – Payment is due on or before the day of service. Westlake Psychiatry does not accept insurance; I am fully responsible for all charges. I authorize Westlake Psychiatry, P.A. to keep my payment card on file and to charge it automatically—before or after an appointment—for any amounts I owe, including but not limited to missed visits, late cancellations, extra time, collaboration, documentation, supplies, and facility use, until I revoke or replace the card in writing for future charges. All charges are calculated in good faith at then-current rates, and I will not claim surprise billing.
Prescription Refills, Clinical Questions & Follow-Up – I will contact the office one week in advance for refills. I will be responsible for double checking all dosing specifications and instructions and accept that I am responsible for clarifying and correcting prescription errors should they occur. I will double check all prescriptions to ensure they are correct, and will immediately seek clarification if unsure. I will schedule appointments for clinical questions and adhere to recommended follow-ups to remain in care.
Good-Faith Care, Medication Risks & Negligence – I acknowledge and accept that all treatment carries risk, including unforeseen reactions to on-label or off-label medications. I will not hold Westlake Psychiatry or its clinicians liable for adverse reactions or unintentional errors.
Independent Providers & Limited Liability of Westlake – Westlake Psychiatry is a professional association of independently contracted, independently insured clinicians. Each provider—whether seen in-house or by referral—is solely responsible for their own clinical acts and decisions and I accept that liability does not extend to supervising or collaborating clinicians named on prescriptions or medical records under Texas law, nor to Westlake Psychiatry or its other professionals.
To the fullest extent permitted by law, I—and my heirs, family members, successors, and assigns—waive and release Westlake Psychiatry, P.A., its owners, employees, contractors, and agents from all claims for injury, damage, economic loss, data breach, or ordinary negligence arising from my care.
Capacity to Consent & Testamentary Intent – I affirm that I have the capacity to enter this Agreement freely and voluntarily and consistent with Westlake Psychiatry’s policy of beginning treatment relationship with individuals capable of providing full informed consent at the time of signing, I intend this document to serve as a binding statement of my wishes and releases, executed in good conscience.
Scope of Services & Legal Matters – Westlake Psychiatry provides clinical treatment only. I acknowledge and agree that Westlake Psychiatry and its clinicians do not provide forensic services, do not evaluate or render any opinion or recommendation regarding custody, conservatorship, possession or access, or parental fitness, and do not provide letters, reports, affidavits, or testimony for use in any legal proceeding. Where such services are sought, a referral will be provided. Any participation compelled by subpoena or court order is billed under Item 4.
https://www.westlakepsychiatry.com/privacy-policy). Comprehensive Acknowledgment – I have read, understood, and accept this Agreement and the Westlake Psychiatry Privacy Policy (https://www.westlakepsychiatry.com/privacy-policy).

Notice of Practices

This Notice outlines how your health information may be used or disclosed by Westlake Psychiatry and your rights regarding this information. Unless otherwise agreed upon in your Conditions of Service Agreement, this document governs how we handle your health information. Please read it carefully.

I consent to follow-up & informational text messages. Simply notify our office or reply STOP to opt out.

Health Information Use and Disclosure Without Your Authorization

Your health information may be used or disclosed primarily for treatment, payment, or operational purposes.

Examples include:

• Treatment: Scheduling appointments, consulting with other providers, and managing your care plan.

• Payment: Generating invoices and collecting payments for services rendered.

• Operations: Quality assurance, staff training, or legal and administrative purposes to maintain the practice.

Limited Disclosures Without Authorization

In certain situations, we may use or disclose your information as required by law. Examples include public health reporting, legal compliance, or addressing safety concerns. These situations are uncommon but permitted under applicable regulations.

Specific Uses Requiring Authorization

Westlake Psychiatry does not sell health information or engage in marketing activities requiring your consent.

Your Rights Regarding Health Information

You have several rights concerning your health information, including:

• Access and Copies: You may request a copy of your health information per our Conditions of Service.

• Amendments: You may provide reasonable written supplementation to your file if you believe there may be an inaccuracy. We will always put forth our best faith effort to ensure your records are accurate.

• Restrictions: You may request limits on the use or disclosure of your information.

• Confidential Communications: You can request in writing that we communicate with you in specific ways, or change your communication preferences in keeping with the terms in our Conditions of Service.

• Accounting of Disclosures: You may request a record of certain disclosures made over a specific timeframe.

To exercise these rights, you must submit a written request to Westlake Psychiatry via fax at (512) 600-3122.

Conditions of Service Agreement Supremacy

The Conditions of Service Agreement you agree to with Westlake Psychiatry takes precedence over this Notice. Westlake Psychiatry operates as a fee-for-service practice and does not bill insurance or coordinate benefits electronically. Westlake Psychiatry is not considered a HIPAA covered entity. Texas Privacy Law and our steadfast commitment to your privacy are foundational to our services and we endeavor in good faith to always ensure the dignity and respect of all of our patients.