Our goal is to start a newsletter that allows patients to be more informed with our offices. This newsletter will be emailed to you, under HIPPA regulations and your information will be kept in complete confidentiality. If you subscribe to this newsletter and decide at a later date that you do not wish to receive it any longer, you can simply unsubscribe to it. Please write your information below, with your signed consent, printed name and we will send you your newsletter.
If child:
Father's Name: Fathers Name Mother's Name: Mother's Name
Insurance & Payment Contract
- I authorize release of information to all my insurance companies.
- I understand that information I give my doctor will be kept confidential, but my doctor is required by law to report evidence of child abuse.
- I understand that I am responsible for my bill.
- I understand that I am responsible for payment for any and all missed session for which I do not notify the doctor of the cancellation at least 24 hours in advance, a $40 fee will be charged to you, for a same day cancellation.
- Therapist appointments, there will be a $60 same day cancellation fee charged to you.
RESPONSIBILITY FOR FEE
I, * , regarding patient understand that Crasmere Psychiatric Services, P.C. will submit claims to my insurance company for reimbursement. If these charges are not reimbursed by my insurance company, due to the services not being covered, prior approval from the insurance company not obtained due to my not informing the office that approval is necessary, my benefits being exhausted, my managed care sessions being used up, or any other reason that the insurance company does not pay for my visits, I realize that I am ultimately responsible for these charges.
PATIENT ACKNOWLEDGEMENT
I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Crasmere Psychiatric Services, P.C.
CONSENT TO EMAIL USE
As a supplement to your in-office appointments, we are inviting you to use email to communicate with our practice. Set forth below are policies outlining when and how email should be utilized to maintain your privacy and to enhance communication as well as a place for you to acknowledge your consent to its use. Your decision to utilize email is strictly voluntary and your consent may be rescinded at any time. Email will be accessed by Crasmere clinical provider or a staff member on a regular basis. You may expect any required response within 24 hours.
When may I use email to communicate with the office?
Email may be used to:
When should I NOT use email to communicate with the office?
Email should never be used:
What are the risks of using email?
Risks of communicating via email include but are not limited to:
What happens to my messages?
What happens to my obligations?
What steps has Crasmere Psychitric Services, P.C. taken to protect the privacy of my email communication?
What steps can I take to protect my privacy?
By signing below, I consent to the use of email communication between myself, * , and Crasmere Psychiatric Services, P.C. I recognize that there are risks to use its use, and despite doctor's efforts, he/she can not absolutely guarantee confidentiality. I understand and accept those risks and the policies for email use outline in the form. I further a free to follow these policies and agree that should I fail to do so, the doctor may cease to allow me to use email to communicate with him/her. I also understand that I may withdraw my consent to communicate via email at any time by notifying the doctor in writing.Name of Patient/Guardian: * Date: * Email Address: *
Patient Name: First Name * Last Name * I also hereby consent to the disclosure of my health information of the following purpose to provide diagnosis and treatment to my primary care physician for coordination of care. Date *
Primary Care Physician Information
Name: Name * Address: Address * City: City * State: Zip: Zip * Phone: Phonr *
Your form is saved successfully!
If you want to continue answering your form later, please enter the email address you would like to send the link to:
Something went wrong while saving your answers. Please try again.
We’ve sent you an email with a link to complete your submission.