Release and Assignment: I hereby authorize any plan benefits to be paid directly to Carolina Psychological Associates, P.A., and I understand that I am financially responsible for non-covered services, including those for which authorization or payment has been denied, either by my EAP/Managed Care plan or other payor. If a claim is made by me or Carolina Psychological Associates to any insurance company or companies, or to any other third party payor, I do not object to the release by mail, fax, telephone, cell phone or computer modem, any records or other information about me, or my child, or the services which are provided, including without limitation, the complete case record, information concerning any personal, psychological and medical history, information concerning billing and payment for such services. I understand that modern communication modalities, such as cell phone, email, and fax, are subject to difficulties. I understand that Carolina Psychological Associates, P.A. will exercise all reasonable precautions, and I in no way will hold Carolina Psychological Associates, P.A. liable for any difficulties resulting to me or any other family member from the communication of confidential information by means of email, fax or cell phone. I agree that all such information shall be subject to review by such insurance company or third-party payor during the period of my or my child’s treatment by Carolina Psychological Associates or at any other time thereafter. North Carolina State law allows mental health and medical providers to share client information with other mental health providers, without obtaining the client’s written consent, when necessary to coordinate care and treatment. This applies between mental health providers and other health care providers and is regulated by Federal HIPAA Laws (1999). This allows a referring psychotherapist or physician to be informed about a client they have referred.