Payment is expected at the time of service. Paradise Behavioral Health only accepts debit card or credit card as a form of payment. Paradise Behavioral Health DOES NOT accept cash or checks.


Insurance Authorization


I authorize payment of medical benefits billed to my insurance by Paradise Behavioral Health. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my insurance, if Paradise Behavioral Health does not participate with my insurance. I hereby authorize Paradise Behavioral Health to use and/or disclose my health information, which specifically identities me or which can reasonable be used to identify me, to carry out my treatment, payment, and healthcare operations.


I understand that while this consent is voluntary, if I refuse to sign the consent, Paradise Behavioral Health can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that Paradise Behavioral Health took before receiving my revocation.


A photocopy of my insurance card will be considered as effective and valid as the original.

When you schedule an appointment with Paradise Behavioral Health, we set aside enough time to provide you with the highest quality of care. We understand that there are circumstances when you may need to reschedule or cancel your appointment. In order to give us time to fill your vacant time slot, we require you to contact our office a minimum of 48 business hours before your scheduled appointment time.


Please review the details of our appointment policy below:


No Show Policy:
-Definition of No Show: A patient who did not attend their scheduled appointment and did not notify our office more then 48 hours before their scheduled appointment.
-Two (2) No Shows within a 12-month period will result in an automatic discharge from [ProviderPractice].
-No-Show Fee: $115.00


Late Reschedule / Cancellation Policy:
-Definition of Late Reschedule / Cancellation: A patient who contacts our office less than 48 business hours before their scheduled appointment.
-Three (3) Late Cancellations within a 12-month period will result in an automatic discharge from Paradise Behavioral Health.
-Late Reschedule / Cancellation Fee: $75.00


For appointments on Monday and Tuesday, we require notification by 5:00pm on the Thursday before your appointment.


Fees are charged to the patient, not the insurance company, and are expected to be paid in full before rescheduling your next appointment.

As a courtesy, appointment reminders are sent prior to your appointment via text message, email, and phone call. If for some reason you do not receive a reminder call, text, or email, the above policy will remain in effect.

-Patient must be seen by their provider a minimum of every 3 months.
-A urine drug screen (UDS) must be submitted when requested by your provider.
-Paradise does not process emergency refills.
-Refill requests are only processed by Paradise Monday-Thursday.
-Refills must be requested at least 1 week before you run out of medication. Please check when your prescription expires and plan accordingly. Call your pharmacy to check on the status of your prescription before making any refill requests to our office.

Telemedicine Policy

I, [ResponsiblePartyName], hereby consent to engaging in Telemedicine with Paradise Behavioral Health as part of my psychiatric evaluation and treatment. I understand that “Telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.


I agree to the following telemedicine policy:


– I will not be in a moving vehicle.
– I will not be in a public area. I will be in a private and quiet room. I will treat this like a regular in-office appointment.
– I will have my medication available during the telemedicine appointment.
– If the patient is a minor, the parent or legal guardian must be onsite.
– If these requirements are not met, I understand my provider will automatically end my appointment and I am responsible for rescheduling to a later date. I understand this will be considered a No-Show and I will be charged a No-Show fee.

In order for us to enhance communication and patient experience, you will be required to register for a Patient Portal. If you are a new patient, we will send you an e-mail with a link to start the registration process. 


Use your patient portal to:
– Request refills
– Message your provider
– View your chart records
– Pay your bill
– Sign forms


Log into your patient portal here.

I voluntarily seek and authorize Paradise Behavioral Health to provide assessment and treatment for services with the following understanding of the above information and the following:


– I agree to participate in the treatment that I agreed to with my provider.
– In the event that I cannot keep my scheduled appointment, I will reschedule or cancel a minimum of 24 hours before my appointment time.
– I agree to go directly to the nearest emergency room or crisis center if I have any thoughts of harming myself or others. Paradise Behavioral Health IS NOT a crisis or emergency facility.
– I agree to allow Paradise Behavioral Health 3 business days to complete any medication refill requests.
– I agree to notify Paradise Behavioral Health 3 business days prior to my scheduled appointment regarding any insurance changes.
– I understand that if I have an issue with Paradise Behavioral Health, I will discuss the issue with the office manager and not cause a disruption in front of other patients and staff.
– I agree to treat all staff and providers with respect. Raising my voice, cursing, or using any disruptive behavior will result in an automatic discharge.

Paradise cannot provide any service for out of state residents. For a patient to be considered a Florida resident they must have a valid ID with a Florida address and their pharmacy must be in Florida.


For patients that have multiple residences in different states, they must prove they have a Florida address by either government ID or utility bill AND have a pharmacy in their chart within the state of Florida.


If a patient is out of state due to vacation, school, or work we can still provide services as long as their primary residence is still within Florida.


Once a patient permanently moves out of Florida we must recommend they find a provider in their local area and will discharge the patient from Paradise.


The only exception to this policy is if the provider is licensed and registered in the same state as the patient.

I have read or had explained to me Paradise Behavioral Health’s Privacy Policy which includes but are not limited to:

– I have the right to limit who has access to my personal health information.
– I have the right to choose how healthcare providers communicate with me.
– I have the right to complain about the unauthorized disclosure of my personal health information.
– I have the right to refuse any procedure or treatment.
– I have the right to an explanation, in a language that I understand, the potential risks, benefits, and the consequences of not participating in the treatment.
– I am entitled to request information regarding alternative treatments.
– The treatment setting will be safe, free of physical and sexual harm, other abuses, threats, acts of violence, weapons, and illicit drugs.
– I understand that I am expected to be free of the influences of alcohol and illicit/non-prescription drugs.
– I agree to follow treatment plan recommendations.
– A record of treatment and conditions will be prepared and kept current and it will be considered confidential except as allowed by the law.

Authorization to disclose protected health information for treatment, or for Health Care Operations (§164.508(a))

I understand that as part of my medical care, this Practice originates and maintains health records that describe my medical history, symptoms, tests and exam results, diagnosis, treatment, and any plan for future care or treatment. I understand that this information serves as:

– A basis for planning my care and treatment.
– A means of communication between health professionals who can contribute to my medical care.
– A source of information to apply my diagnosis and surgical information to my bill.
– A means by which a paying third party can verify that the billed services were actually provided.
– A tool for routine health care operations such as assessing quality and reviewing the capacity of health professionals.


I have been given a copy of the Notice of Practice Privacy with a more complete description of the uses and information disclosures.

I understand that as part of my care and treatment, it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review the notice of this Practice before signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and the parts designated by me.