2784 EAST 12TH, ST, RM 4A BROOKLYN NY 11235
Thereby assign all my health benefits to include all major medical/mental health benefits to which I am entitled. I authorize use of my signature on insurance claims and submissions. I authorize and direct my insurance carrier(s) to issue payment directly to New Patterns Therapy LCSW PC for services rendered to myself or my dependents, regardless of my insurance benefits. I understand that I am responsible for any uncovered amount not covered by my insurance.
I agree to allow New Patterns Therapy LCSW PC to (1) release any information necessary to insurance carriers regarding my diagnosis and treatment, (2) process insurance claims generated in the course of an in person or telehealth visit. I have requested behavioral health services from LCSW, Yana Godmach on behalf of myself or my dependants, and understand that by making this request, become fully responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
In an effort to provide effective and efficient treatment to all of our patients, it is the policy of this practice that all appointment cancellations are made at least 72 hours prior to your scheduled appointment time.
If an appointment is not canceled within 72 hours prior to the scheduled appointment time or if the patient fails to show up for the appointment, New Patterns Therapy LCSW PC reserves the right to charge the patient a $70 fee per occurrence. As this fee is not billed to any insurance company, the patient accepts full responsibility to pay this fee.
Consent and Acknowledgment Statement:
By signing below, I confirm the following:
I understand that telehealth services involve the use of electronic communications (video and/or audio technology) that allow the clinician and client to communicate without being physically present in the same location. Telehealth services are provided in accordance with New York State telehealth regulations.
Confidentiality: Telehealth services are protected by the same confidentiality laws that apply to in-person treatment, including HIPAA and New York State confidentiality requirements, except where disclosure is required or permitted by law.
Potential Risks: Risks may include interruptions due to technical problems, unauthorized access to electronic communications, or limitations in the clinician's ability to observe nonverbal behavior.
Right to In-Person Services: I have the right to request in-person services, when available and clinically appropriate.
Emergency Procedures: Telehealth services may not be appropriate for emergencies. In the event of an emergency, I will call 911 or go to the nearest emergency room.
Location Disclosure: I agree to inform the clinician of my current physical location at the start of each telehealth session.
Minor Consent: For clients under age 18, parent/legal guardian consent is required for participation in telehealth services.
