Please take a moment to review this pertinent information to which you are entitled before receiving psychiatric and mental health services.
Any information you disclose will be maintained in the strictest confidence, unless you specifically authorize its release, or unless law or professional standards of practice require its release. In particular, your right to confidentiality many not be maintained, if you are in immediate danger to harm self or another person. Also, any clinician hearing about domestic violence in the presence of minors, physical, sexual, or emotional abuse of minors, dependent adults, or elderly adults is required and mandated by law to report this information to a designated agency for assistance. If it is necessary to seek help from an outside agency for any of the above-mentioned situations, this will be discussed with you for verification before taking any further action.
Psychotherapy is not like a medical visit; in fact, it requires an active participation on the patient’s side and each session may not end with a sense of relief or satisfaction as sometimes the growth is to happen after the session when the patient has time to process and think about the topic of discussion. Psychotherapy can have benefits as well as risks, since often the discussion involves unpleasant aspects of life. Therefore, you may experience sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, Evidence Based Psychotherapy (EBP) often leads to better relationships, solutions to specific problems, and significant reduction in feelings of distress.
Please try to keep your appointment schedules, should you need to cancel or reschedule an appointment, please do so with at least 24 hours advance notice. Otherwise, the time will be held open, and you will be charged your regular rate for the cancelled visit.
All outpatient visits will have to be paid at the time of the service, if we are not in network with your insurance carrier. In such cases you will be provided with a superbill to submit to your insurance company for eligibility payment depending on your insurance carrier terms for out of network providers. We cannot accept responsibility for negotiating claims with insurance companies or other third parties. We are currently working towards credentialing with most insurance companies and as soon as such information is released, we will inform our patients and update their payment methods. Sometimes it is possible to obtain a Single Case Agreement (SCA) with some insurance companies as the out of network provider, if this is the case, we will collaborate with insurance for your claim.
I have read and understood the foregoing, and I consent to this evaluation or treatment.
I hereby authorize Annie Zadori, PsyD (PSY 32733) to release any and all medical information to my insurance carrier for purposes of claims administered and evaluation, utilization review, and financial audit. This authorization remains in effect from date of signing until revoked in writing. I understand that I may request a copy of this authorization.
The documents including and/or accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for return of these documents.
