CONNIE CHA, M.D.
​Office: 650-521-9915
Fax: 1-844-647-2558​
HomeAboutContact / DirectionsOffice Info & Forms

Office Information
Please click on links for further information about Dr. Cha's office policies. Please sign each form prior to your appointment. 
Click to download Office Policies form



Click to download Patient Information & Confidentiality form



Click to download Payment Method form



Click to download Credit Card Authorization form





Professional Services:

Initial Evaluation (First 2 sessions)45 minutes each session
Follow-up appointments (med management/psychotherapy):45 minute and 30 minute sessions


Payment Information

Please note that I do not currently accept any insurance policies. I will provide you an invoice for the visit that you can submit to your insurance company for reimbursement. Please check with your insurance company regarding their policies on this. Questions to ask regarding your insurance coverage include:

1.Does my plan cover mental health benefits?
2.Does my plan cover psychiatric medication?
3.How many sessions are covered?
4.Does my plan cover out-of-network providers?
5.What is the reimbursement rate? 

I will expect payment at the beginning of each session.  
I accept cash or major credit cards. I do not accept personal checks.


FAQ's 

Q: Do you take insurance?

A: I am considered an "out-of-network" provider for all insurance. This means that you pay the full amount at the time of service and may then submit a claim to your insurer. Your insurer will then send you a percentage of this fee directly. 

Q: How do I file out-of-network claims? 

A: You can call your insurer or look on their website to find out how out-of-network claims are processed. I will provide you with an invoice that you submit along with any other paperwork required by your insurance. 

Q: Do you have a co-pay? 

A: I do not have a copay because I am not in-network with your insurance. At the time of service, you are expected to pay in full for your appointment.

Q: What forms of payment do you accept? 

A:I accept cash or credit card (Mastercard, VISA, or Discover) at the time of service. I require a credit card on file. 


Office Policies

  Fees are due and payable at the time of the visit, unless prior financial arrangements have been made. Please include your complete name on the check. This office does not deal directly with insurance carriers. Your statement will include all of the information necessary for insurance claims. We suggest that you submit the claim as soon as you receive the statement and keep a copy for your records. The patient or responsible person is ultimately accountable for all fees due to Dr. Cha.

  Charges will incur after the second appointment is missed without prior notification. Full session fee will be charged for cancelled or missed appointments unless 2 business days' notice has been given (i.e. an appointment scheduled for Wednesday at 2 pm would have to be cancelled by Monday at 2 pm in order for a charge not to be incurred). It is required that a credit card be on file for each patient in the event of missed sessions or late payments. 

  For patients on medication, please allow two business days for a prescription refill if you will not be seeing Dr. Cha before running out of medication. Please state the full name of the patient, birth date, medication name, dosage, frequency and pharmacy telephone number in your message.

  In the event of an emergency, Dr. Cha can be reached at the number listed at the top of this page. If you are unable to reach Dr. Cha, you should leave a message and then call 911 and/or proceed to your nearest emergency room.