Additional services not covered by insurance companies include:

1. FMLA, long term medical leave/extensive forms: $50.00
2. Short medical leave, short-term leave forms:
   $25.00
3. Late cancel without a 24-hour notice or No-show fee: $50.00
4. Returned check fee: $35.00
5. Medical record copying will be charged according to State of Michigan rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.

Credit Card Information: Pure Psychiatry of Michigan may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Rest assured that your credit card information will be securely stored and processed in compliance with all relevant regulations.