PATIENT ACKNOWLEDGEMENT AND AGREEMENT

The information provided above will be used during the intake session. I have accurately provided the information above to the best of my knowledge.

I am pleased that you have chosen me to help. I look forward to the opportunity to work with you. Mental health issues are unique in that invaluable information is conveyed nonverbally through gestures and through inflection of speech. Therefore, I provide the highest quality of treatment through face-to-face contact. Most of the policies outlined in the following forms and summarized below are meant to encourage at least phone contact and at best face-to-face contact. While these issues have been covered in the other forms, I have reiterated them here for emphasis and for clarity. Please review and sign below.

If you have a clinical emergency and you need immediate assistance, please call 911 or go to your nearest emergency room. 

Patients are seen by appointment only.

Please provide at least 1 business day notification, from the time of your appointment, for cancellation to avoid a no show fee. For example, to cancel a 9:00am appointment on Monday, I need to know by 9:00am Friday that you intend to cancel. The no show fee is equivalent to the cost of the appointment. Insurances do not reimburse for no show fees.

I check my voicemail and email/text on weekdays between regular business hours. To be clear, I do not check messages on Sundays or national holidays. I will respond to messages often on the same day but sometimes it may take up to 2 business days for a response depending on the matter. Please note, if you leave a message on Friday, you may not receive a response until Monday.

Email and texting carry inherent risks (see your Email/Texting Consent Form for details Email/texting should be limited to brief logistical issues or facilitating the collection of background information, e.g. scheduling appointments, obtaining medication refills, and/or sending forms or past mental health evaluations. Current clinical matters that could be construed to request clinical advice should be called in by phone or discussed face-to-face in an appointment. If you email/text clinical matters, e.g. your current mental status or problem, I will NOT provide advice by email/text. You will receive a phone call within 1 business day. Do not email/text life-threatening matters; these should either be called to 911 or my urgent line. Inappropriate use of email/texting will incur charges of at least $25 and prorated based on time spent to address the issue at $450/hr. at 5 minute increments.

All forms are charged at a base rate of $25. If they take longer than 5 minutes, they will be billed at $450/hr at 5 minute increments. For those with PPO insurances, you can save money by arranging an appointment during which the form(s) are completed. The forms would be considered part of the appointment and you would receive partial reimbursement.

Consent to Evaluate/Treat

I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by Margarita Krasnova, MD. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:

a. The benefits of the proposed treatment b. Alternative treatment modes and services

The manner in which treatment will be administered

d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable e. Probable consequences of not receiving treatment

Evaluation and treatment may be administered with psychological interviews, psychotherapy, pharmacotherapy, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my (or my child's) daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic performance, health status, quality of life, and awareness of strengths and limitations.

I also understand that, while the purpose of treatment is designed to be helpful, risks are possible. These include side effects from medications. In addition, psychotherapy may be at times difficult and uncomfortable as emotionally laden topics are confronted and explored.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment for myself (or of my child If applicable, I also attest that I am the legal guardian and have the right to consent for the treatment of this child. I understand that I have the right to ask questions of my child's service provider about the above information at any time.

1. Emergency and Urgent Communication

Emergency Problems: Email/texting should never be used for emergency problems. In the event of an emergency, please call 911 immediately.
Urgent Problems: Email/texting should not be used for urgent problems. In these cases, the patient should call 911, go to an urgent care or immediate care facility. 

2. Non-Clinical Urgent Communication (Appointments, Scheduling)

You may contact me via text or phone call on my dedicated phone line for non-clinical urgent matters, such as scheduling or rescheduling appointments. Please do not share any sensitive personal health information through text or phone unless absolutely necessary.

3. Clinical Communication (Medications, Symptoms, Health Concerns)

For any communication related to your health, such as discussing medications, symptoms, or other clinical concerns, please use the encrypted HIPAA-compliant email provided to you. This method ensures that your personal health information is securely transmitted and protected.

4. Risks of Using Email/Texting to Communicate with Your Provider

Email/texting has a number of risks that patients should consider before using these methods to communicate with me. These include, but are not limited to:

• Email/texting can be circulated, forwarded, and stored in numerous paper and electronic files.
• Email/texting can be immediately broadcast worldwide and received by unintended recipients.
• Email/texting senders can easily type in the wrong email address or phone number.
• Email/texting is easier to falsify than handwritten or signed documents.
• Backup copies of email/texting may exist even after the sender or recipient has deleted their copy.
• Employers and online services have a right to archive and inspect e-mail/textings transmitted through their systems.
• Email/texting can be intercepted, altered, forwarded, or used without authorization or detection.
• Email/texting can be used to introduce viruses into computer systems.
• Email/texting can be used as evidence in court.

5. Conditions for the Use of Email/Texting

I will use reasonable means to protect the security and confidentiality of email/texting information sent and received. However, because of the risks outlined above, I cannot guarantee the security and confidentiality of email/texting communication and will not be liable for improper disclosure of confidential information not caused by my intentional misconduct. By signing below, you consent to the use of email/texting for communication under the following conditions:

• All email/texting concerning diagnosis or treatment may be made part of your medical record.
• I may forward email/texting internally to staff as necessary for diagnosis, treatment, reimbursement, and other handling.
• I will not forward emails/texting to independent third parties without your prior written consent, except as authorized or required by law.
• I shall confirm when an email/texting from you has been received and read. However, you should not use email/texting for medical emergencies, urgent problems, or other time-sensitive matters.
• If your email/texting requires or invites a response from me and you have not received a response within a reasonable time period, it is your responsibility to follow up.
• You should not use email/texting for communication regarding highly sensitive medical information, such as information about sexually transmitted diseases, HIV, mental health, developmental disability, or substance abuse.

6. Patient Responsibilities and Instructions

To communicate by email/texting, you should:

• Limit or avoid the use of your employer’s computer for email/texting.
• Inform me of changes to your email address or phone number.
• Confirm that you have received and read my email/texting.
  Put your name in the body of the email/texting.
• Include the category of the communication in the email/texting’s subject line for routing purposes (e.g., billing question).
• Review the email/texting to make sure it is clear and that all relevant information is provided before sending it.
• Take precautions to preserve the confidentiality of email/texting, such as using screen savers and safeguarding your computer password.
• Withdraw consent only by email/texting or written communication to me.

7. Alternate Forms of Communication

You may also communicate with me via telephone or during a scheduled appointment. Email/texting is not a substitute for the care provided during an office visit. Appointments should be made to discuss any new issues as well as any sensitive medical information.

8. Types of Email/Texting Transmissions

The types of information that can be communicated via email/texting include prescription refills, patient referrals, appointment scheduling requests, and patient education. If you are unsure if the issue you wish to discuss should be included in an email/texting, please call the office to schedule an appointment.

9. Security Measures Used by the Provider

While email/texting comes with privacy risks as outlined above, I will use reasonable safeguards to protect your healthcare information as required by law. These safeguards include password-protected screen savers, policies and procedures, staff training requirements, and encrypted email.

10. Hold Harmless

I agree to indemnify and hold harmless the Provider from and against all losses, expenses, damages, and costs, including reasonable attorney’s fees, relating to or arising from any information loss due to technical failure, my use of the internet to communicate with the Provider or the use of the Provider’s website, any arrangements you make based on information obtained at the site, any products or services obtained through the site, and any breach by me of these restrictions and conditions.

11. Termination of the Email/Texting Relationship

I reserve the right to immediately terminate the email/texting relationship if I determine that you have violated the terms and conditions set forth above, breached this agreement, or engaged in conduct deemed unacceptable.

12. Forwarding Email/Texting

There may be times when I must forward the information you have provided via email/texting to a third party for treatment, billing, and payment purposes. By signing below, you expressly consent to allow me to forward these emails/texts under these conditions. 

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I have discussed with the Provider or his/her representative and I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail/texting between the Provider and me, and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by e-mail/texting. Any questions I may have had were answered.

I am agreeing to compensate Dr. Krasnova based on her fees as set below:

1. Adult initial evaluation (90 min): $675.

2. Medication management/supportive psychotherapy (25 minute visits): $250.

3. Medication management/ psychotherapy (45 minute visits): $350; (60 minute visits): $450.

4. A re-evaluation (60 minutes) is required when patients have not been seen within 5 months of their last appointment: $450.

5. Any type of correspondence or service not mentioned above (including but not limited to phone calls, completing forms, obtaining collateral information, etc) that require more than 5 minutes will be billed at $450/hr.

6. Cancellations that occur within 1 business day of the appointment and no shows will be charged at the rate of the appointment.

PAYMENTS.

I am responsible for payment in full. Electronic payment in the form of IvyPay is accepted. Credit card information will be requested prior to the first appointment. Defaulted accounts will be sent to collection.

The federal government has enacted a broad and complicated collection of regulations under the title of HIPAA (Health Insurance Portability and Accountability Act A major part of this legislation, the Privacy Act, addresses privacy and confidentiality of patient medical information.

HIPAA requires us to give all patients a notice of health information privacy practices, which you have received. We are happy to comply with the law in distributing this notice. In our opinion, however, the new law can be confusing and overly complicated. Therefore, Margarita Krasnova, MD, is also issuing a statement about our own policy regarding privacy and confidentiality.

M Krasnova, MD's Long Standing Policy Regarding Patient Privacy and Confidentiality

Confidentiality is an essential cornerstone of psychotherapy and mental health treatment. Margarita Krasnova, MD has always maintained the highest standards and safeguards of patient privacy and confidentiality. Our policy is straightforward: We will not release information about treatment to anyone without specific permission of the patient/client unless required by law. There are some situations, not related to HIPAA, which have always mandated a breach of confidentiality. For example, if a therapist believes there is serious danger of patient self-harm, danger to a third person, or if there may be abuse of an elder or child, then the appropriate authorities must be informed.

Margarita Krasnova, MD will continue to hold the highest standards of patient privacy and confidentiality. The Privacy Act, in fact, permits disclosure of some information without the permission of the patient. However, Margarita Krasnova, MD will not release that information even though the new Privacy Act permits.

Margarita Krasnova, MD will continue to talk to a patient/client any time there is a new request for information about diagnosis or treatment. Each request will be discussed with the individual and permission obtained before disclosure is made. Even in cases where records are ordered by a court, it is sometimes possible for the therapist to negotiate a compromise so that the court decides only what minimal information is required. Much personal and private information can still be safeguarded in this way.

Please feel free to ask Dr. Krasnova if you have any questions or concerns.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I certify that I have been provided information about, and a written copy of, M. Krasnova, M.D., Inc. Notice of Health Information Privacy Practices (FORM 5) and how this pertains to Protected Health Information (PHI)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMTION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice please contact M. Krasnova, MD.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and that control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to above by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. This new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised revision by accessing my website, or calling the website and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice.

Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. 

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provide (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. 

Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

We will share your protected health information with third party "business associates" that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact Margarita Krasnova, MD to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact Margarita Krasnova, MD and request that these fundraising materials not be sent to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

2. YOUR RIGHTS

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Margarita Krasnova, MD if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by contacting Margarita Krasnova, MD.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to Margarita Krasnova, MD.

You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact Margarita Krasnova, MD if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3. COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. Their contact information is:

California Health and Human Services

1600 Ninth Street, Room 460

Sacramento, CA 95814

(916) 654-3454

You may file a complaint with us by notifying Margarita Krasnova, MD of your complaint. We will not retaliate against you for filing a complaint.

You may contact Margarita Krasnova, MD at 310-961-4896 for further information about the complaint process.

This notice was published and is effective on 12/13/13.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

I have read and understood the above and have had an opportunity to ask questions about this information. I certify that I understand the terms set forth above and that I agree to the privacy practices enlisted herein.

Telepsychiatry provides psychiatric services using interactive video conferencing tools, such as Zoom, in which the psychiatrist and the patient are not at the same location. Telepsychiatry will allow the patient to receive medical care without the need to visit the office and travel long distance. Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of video); delays in medical evaluation and treatment due to deficiencies or failures of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face to face visit may result in errors in medical judgment. 

Your Rights:

1) I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry. 

2) I understand that the Zoom is known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. I am using HIPAA protected Zoom platform.

3) I have the right to withdraw my consent to the use of telepsychiatry during the course of my care at any time. 

4) I understand that Dr. Krasnova has the right to withhold or withdraw consent for the use of telepsychiatry during the course of my care at any time.

5) I understand that all rules and regulations which apply to the practice of medicine in the State of California also apply to telepsychiatry. 

Your Responsibilities: 

1) I will not record any telepsychiatry sessions without the prior written consent of Dr. Krasnova and I understand that Dr. Krasnova will not record telepsychiatry sessions without my consent. 

2) I will inform Dr. Krasnova if any other person can hear or see any part of our session before the session begins. Likewise, Dr. Krasnova will inform me if any other person can hear or see any part of the session before the session begins.

3) I understand that I MUST be a resident of California to be eligible for telepsychiatry

4) I understand that my Initial Consultation will not be done by telepsychiatry except in special circumstances under which I will be required to verify my identity to Dr.Krasnova's satisfaction before the evaluation.

 

 

PATIENT ACKNOWLEDGEMENT AND AGREEMENT

Your signature below indicates that you have read and understand the information provided above regarding telepsychiatry, and that you authorize Dr. Margarita Krasnova to use telepsychiatry in the course of diagnosis and treatment.