Patient Terms, Conditions, Rights, & Responsibilities

Patient Terms, Conditions, Rights, & Responsibilities

Indiana Health Group’s mission is to set the standard of excellence by providing compassionate, comprehensive behavioral health and substance abuse treatment of individuals of all ages, couples, and families in a safe, private, and comfortable environment.  Our multi-disciplinary team of highly trained professionals are committed to “Changing Lives Together” by providing a broad range of patient centered services tailored to the unique needs of each individual patient. IHG strives to be the facility of choice by exceeding the expectations of those we are privileged to serve.


Indiana Health Group is a private practice and we do not provide emergency / crisis services.
For medical / behavioral healthcare emergencies, please call 911, go directly to the nearest emergency room, or contact Community Hospital North Crisis Center at 317-621-5700.


        We strongly recommend that if you are not yet connected to our practice patient portal, My Medical Locker (MML), that you do so as soon as possible. MML is a HIPAA-compliant, secure messaging system that you can use to connect with Indiana Health Group for almost all your needs. Using My Medical Locker allows you to have more clear communication with your clinician as they will receive your message in your own words. It also allows for a record of our communication and provides us with a way to provide you with more detailed information to which you can later refer if you have questions. Messages sent through My Medical Locker are received by our staff more quickly, since these messages are available in our system as they come in throughout the day as opposed to voice mail messages which are typically retrieved at various times throughout the day.
      • EMAIL
        Is the next best option to send a quick communication to our staff.
        Appointments and all other requests:
        Billing: Billing@indianahealthgroup.comclick here to make an online payment
        317.843.9922. Please follow the menu prompts to be connected to the appropriate department.
        Our office receives well over 1,000 phone calls each day, so using the patient portal when appropriate provides our staff with a greater ability to field phone calls for issues better addressed through real-time communication.


      • TELEHEALTH – Please check-in on our website at at the time of your appointment. Simply click on PATIENT CHECK-IN under the TELEHEALTH TAB.
      • TELEPHONE – No check-in required. Your provider will contact you by phone at the time of your appointment.
      • OFFICE – Check in with our front office staff upon your arrival.


Recognizing that everyone’s time is valuable, we ask that you provide a 24-hour notice if you are unable to keep your appointment. Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care.

      • LATE CANCEL – A charge of $50.00 up to full fee will be applied for EACH appointment cancelled with less than a 24-hour advance notice as well as appointments in which you arrive past your scheduled appointment time.
      •  MISSED APPOINTMENT – A charge of $75.00 up to full fee will be applied for EACH appointment that is missed without notification. The amount of the charge is left at the discretion of the provider.
      • LATE ARRIVAL – If you check-in late for your scheduled appointment, it is at the discretion of your service provider if you will be able to be seen. Your appointment will not be extended due to your tardiness. It will end at the original scheduled time. If you late arrival results in a missed appointment, a charge of $50.00 up to full fee will be applied to your account.

Multiple missed, late cancelled, or late arrival appointments will result in an inability to continue to provide services to you.


We highly encourage you to address all questions and concerns at the time of your appointment.

*Medication refills WILL NOT be called in outside of normal business hours, weekends, or holidays.

It is recommended patients check with their pharmacy to verify there are no refills on file or on hold before contacting our office. Sometimes prescriptions are held if they are issued prior to the acceptable refill date. If a refill is necessary, for the quickest response, please request your refill via our patient portal. If you do not have a portal account set up, please see “COMMUNICATING WITH OUR OFFICE” on the previous page for additional ways to reach us.

Indiana Health Group DOES NOT accept automated pharmacy fax refill requests.
Our office receives hundreds of automated fax refill requests daily for medications with a vast majority of those requests being for medications that have been changed or discontinued. Pharmacies are typically unaware of this information. We ask that you initiate all refill requests.

Insurance companies often require a prior authorization be completed. This is a process they use to determine if they will cover the cost of the medication that has been prescribed for your care. The PA will be initiated by your insurance. Our office will submit the requested information to your insurance company. Please note that the final determination is made by your insurance, not IHG or your medical provider.


  • Private Pay Services / Out of Network Insurance Billed Services – Payment is due at the time of service.
  • Insurance Billed Services – Co-payments & deductibles are due at the time of service.
  • Insurance Participation – Our providers participate with different insurance plans. We make every attempt to schedule you with an in-network provider; however, we cannot guarantee that the provider you are scheduled with is active in your network. It is the patient responsibility to confirm that any/all providers with whom they are scheduled are participating in their insurance network. Patients will be responsible for charges incurred for services rendered by an out-of-network provider.
  • Insurance Benefits – Please be aware that mental health benefits are normally different from your medical benefits. Indiana Health Group does not verify insurance benefits information until after your initial visit with our group. It is your responsibility to verify and familiarize yourself with your mental health benefits.
  • Changes to Insurance – It is your responsibility to make sure we have your most current insurance card on file. Sometimes insurance may change to a different insurance company, other times it may just be a simple change to your ID number. Anytime you receive a new card, please notify our office or you can upload a copy through our website.
  • Claims Submission – Indiana Health Group will file all claims with your primary insurance company upon submission of proof of insurance. Indiana Health Group will file secondary insurance claims for contracted insurance carriers only.
  • Past Due Balances – Our office reserves the right to cancel or refuse services for patient accounts with past due balances. Patients will be unable to schedule appointment if they have 2 outstanding co-payments, an account balance of $100 or more, or if your account balance is greater than 30 days past due after insurance processing.
  • Returned Check Fees – All returned checks would be assessed with a $30 processing fee. The original check amount plus the processing fee must be paid at your next appointment or within 10 days, whichever occurs first. Indiana Health Group reserves the right of check refusal.
  • Statements – will be mailed at the beginning of each month. Payment in full is due upon receipt of the statement.
  • Acceptable methods of payment – Cash, Check, Money Order, and bank cards including VISA, MasterCard, Discover and American Express.
  • Claim / charge dispute – Therapist, doctors, nurses, clerical staff, and/or billing department personnel are unable to waive or modify fees. The decision rests with the administration of Indiana Health Group. The patient must complete and submit an account dispute form that is available on our website under the Forms tab.
  • Financial Responsibility – The patient / responsible party are responsible for all charges incurred with Indiana Health Group.
  • Collections – Accounts in violation of our financial policy are subject to placement with a third-party collection agency. The patient will be responsible for reasonable attorney and collection fees.


  • Private Pay Services / Out of Network Insurance Billed Services – Payment in full is due at the time of service.
  • For your convenience Indiana Health Group will file out of network claims upon proof of insurance.
  • IHG is not responsible for obtaining authorization for out of network services.
  • Discounts will not be applied to out of network claims.
  • IHG is not responsible for processing errors caused by the insurance on out of network claims.
  • IHG is not responsible for pursuing payment from the insurance for out of network claims.


  • Forensic / Court / Legal – A $500.00 retainer fee is required. Hourly individual provider fees may vary however, these fees will have a minimum of two times the provider base rate. Payment in full is due at the time of scheduling. Fees are non-refundable unless cancelled 48-hours in advance.
  • Document PreparationDocument review with signature only will be charged a minimum of $10.00. A fee of $50 per every 15 minutes of time required to complete paperwork (including but not limited to work, disability, FMLA, life insurance, etc.) will be charged for all forms completed outside of your schedule office visit. Payment in full is required prior to the release of the completed paperwork.
  • Medical RecordsA current written release of information is required for all requests. All requests for medical records will be charged according to Indiana State Law. Payment is due prior to the processing of your request. There is no charge for records released directly to another healthcare professional for treatment purposes.
  • Case ManagementServices provided outside of scheduled appointment times. (A consultation either via telephone or in person with parties outside of Indiana Health Group, such as family members, school officials, attorneys, physicians, etc.) A release of information is required.


As technology continually changes, Indiana Health Group (IHG) reserves the right to revise this policy.

  • Contacting IHG via Text or Social Media – Please do not use mobile text messaging or messaging on social media sites such as Twitter, Facebook, or LinkedIn to contact IHG.  These sites are not secure. Engaging IHG this way could compromise your confidentiality.  It may also create the possibility that these exchanges become a part of your legal medical record and would need to be documented and archived in your chart.
  • Social Media – IHG and its staff do not accept “friend” requests from current or former clients, or family members of clients, on Facebook, Instagram, Twitter, or other similar social media sites.  IHG believes that adding clients as friends or contacts on these sites can compromise confidentiality and our respective privacy.  It may also blur the boundaries of the therapeutic relationship.  If you have questions about this, please bring them up when during a meeting and these issues can be discussed further.
  • Location-Based Services – If you or your family member has locations enabled on a mobile device, or you check in on a social media site, it could identify you as a patient at IHG. Please be aware that this compromises your confidentiality.
  • Business Review Sites – You may find IHG on sites such as Google, Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses.  Some of these sites include forums in which users rate their providers and add reviews.  Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site.
    If you should find IHG’s listing on any of these sites, please know that the listing is NOT a request for a testimonial, rating, or endorsement from you as a client.  Of course, you have a right to express yourself on any site you wish but due to confidentiality, IHG cannot respond to any review on any of these sites whether it is positive or negative.IHG urges you to take your own privacy as seriously as IHG takes its commitment of confidentiality to you.


Our office utilizes and recommends exclusive use of, a confidential, HIPAA compliant audio/video conferencing application, for all telehealth appointments. Indiana Health Group is not responsible for breach of confidentiality when using any other telehealth platform including over the telephone or via email.

Patient Location:

  • We ask that you be in a private, secure, location for your appointment to reduce the likelihood of your confidential health information being compromised.
  • You must be physically located in the state of Indiana to receive treatment via telehealth from any IHG provider. It is unlawful for our providers to provide treatment across state lines unless they are dually licensed in the state that you are physically present in.

Check In:
Please check-in on our website at at the time of your appointment.
Simply click on APPOINTMENT CHECK-IN under the TELEHEALTH TAB and then click on your providers name to be checked in to their virtual waiting room.
If you fail to check in at the time of your appointment, you could be charged according to our failed appointment policy.

Coverage is determined by your insurance carrier. We highly encourage you to verify your telehealth benefits with your insurance company or your human resources representative.


  • I agree IHG and its members, directors, partners, employees, and agents shall not be liable for any breach of confidentiality or privacy arising from teletherapy with me. I agree that I shall fully defend and hold IHG harmless for principal, interest, court costs and reasonable attorneys’ fees, together with any judgment rendered against it because of or arising from this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy.
  • I agree to waive all claims against or liability of and shall hold harmless IHG and its members, directors, partners, employees, and agents for any breach of confidentiality or privacy arising from teletherapy with me.
  • I agree I am signing this Informed Consent voluntarily and my signature is not the result of duress or undue influence.
  • I agree I have asked IHG all questions I had regarding this Informed Consent, and such questions were answered to my satisfaction.
  • I agree that this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy represents the entire understanding regarding the subject matter herein. I agree that none of the terms of this Request to Use, Informed Consent, And Agreement Regarding Use of Teletherapy can be waived or modified, except by an express agreement signed by me and IHG. I agree there are no representations, promises, warranties, covenants, or undertakings by IHG other than those expressly set forth in this Agreement.
  • This Request to Use, Informed Consent, And Agreement Regarding Use of Teletherapy is made and executed in the State of Indiana and shall be governed and always construed according to the laws of that state even though I may later reside or be domiciled outside of Indiana.


To be treated with respect and recognition of my dignity and right to privacy

Receive care that is considerate and respects my personal values and belief system

Personal privacy and confidentiality of information

Reasonable access to care, regardless of my race, religion, gender, sexual orientation, ethnicity, age, or disability

Participate in an informed way in the decision-making process regarding my treatment planning

Discuss with my treating professionals appropriate/medically necessary treatment options for my condition regardless of cost / benefit coverage

Adequate and humane services regardless of the source(s) of financial support

An individualized treatment or program plan with periodic review of the treatment or program plan

Designate a decision maker if I am incapable of understanding a proposed treatment or procedure or am unable to communicate my wishes

Voice complaints or appeals about my managed care company, provider of care or privacy practices

Be informed of rules and regulations concerning my own conduct

Request access to my Protected Health Information (PHI)

Request to inspect and obtain a copy of my PHI, to amend my PHI or to restrict the use of my PHI, and to receive an accounting of disclosures of PHI


I agree and consent to participate in the mental health services offered and provided by INDIANA HEALTH GROUP, INC., a mental health provider as defined in Indiana law.

I agree to provide (to the extent possible) my treating clinician with information needed to receive appropriate care.

I understand that it is my responsibility to understand my health problems and participate, to the degree possible, in developing, with my treating clinician, mutually agreed upon treatment goals.

I understand that it is my responsibility to follow plans and instructions for care that I have agreed on with my treating clinician.