Michael J Rosen, M.D. Jessica Scott, APRN Jessica Mathisen, LPC

ent threat to self or others, call 911 or go 1. If you/your child are an immin to your nearest emergency room. 2.Notify your provider If there are any significant changes to your/your

child's psychiatric or medical health

any 3.Do not emall the practice with urgent clinical matters. Patients should discuss any clinical concerns directly with their provider. Emails may be sent for administrative purposes after providing advanced verbal notice to our front staff. r 4.Please dlscuss with your provide before increasing, decreasing, or discontinuing any psychiatric medication. Medication changes without consultation can be dangerous your 5.It is your responslblllty to notify provider If you are pregnant or plan to become pregnant. Refrain from driving If your medicatio 6. n makes you feel drowsy or r. otherwise Impaired and notify your provide or use illegal substances while taking 7.It Is advised not to drink alcohol psychiatric medication.

I have read, understand, and agree to the above Important points to

patient Signature of Patient or Legal Guardian (If under 18 years old)

for a minor, you must have either sole custody To provide consent for psychiatric treatment shared legal custody of the chlld. If you share legal custody, and your legal arrangement or ealt h appointments, It Is your responslblllty to requires that you notify the other parent of h dis do so. Please note that any cllnlcal matter cussed during an appointment with one other parent as well. parent present may be discussed with the

a re the ParenVLegal Guardian of By signing below, you are certifying that you

to consent to treatment for your chlld. You also agree to notify If your custody us arrangement changes.

CREDIT CARD POLiey AND CONSENT

• 1, the undersigned, authorize Michael Rosen, M.Dto charge my credit card for the following . services or conditions: appointments or cancelJatlo ns
• Missed not meeting the cancellation requirements herein: I.405.00 for Initial appointment with psychiatrist (MD) II.$200.00;f.Or l nltlal appointment with master level therapist $135.00 -ftfr p p 111. follow-uvisit with psychiatrist (MD), APRN, or master level thera ist iv. $375.00 for initial appointment with APRN
• (unless paid by check or credit/debit card at the time of the CO-Payments appointment)
• to Insurance being Inactive at the time of Any clalm that Is denied secondary service, or due to failure on the part of the patient or responsible party to obtain prior authorization or referral and/or complete forms requlr9d by the Insurance company to process the claim (unless otherwise discussed and agreed by us
• en covered (denied for any reason) y your Any Insurance claim that has not be b Insurance plan becomes YOUR responslblllty 90 days after our proper lnltlal flllng of the clalm.
• The unpaid pat1ent responsiblllty balance Is due no later than 60 days after the date of service.
• Any bounced check amount plus a $60 bounced check fee.
• $60 for providing each "Inter-appointment" prescription.
• $25 fee for completing any brief letter/form.
• pa pe administrative fee plus $.60 ge for a copy of your medical records to r $25 be sent to another physician, therapist, or any other provider.
• $25 fee for completing each "Prior Authorization" form.

Visa □ MasterCard □ □ American Express Discover

t M Consent & Authorization to Release/ Reques edical and Mental Health Information.

hereby authorize Michael Rosen, M.D. to release/request (clrcle one or both) the following Information and records obtained In the course of my diagnosis and treatment. I understand that these records may contain confldentlal Information about psychiatric treatment, substance abuse or dependency, sexuality, and communicable diseases such

(Please check all that apply )

I understand that I have the right to revoke this authorization at any time and that I on must be provided by me In writing and cancellation or modification of this authorizati received by us to be effective. I understand that any use or disclosure/request made prior to the revocation of this authorization wlll not be affected by the revocation.

understand that I have the right to refuse consent and signing of this authorization and I p that my treatment or the treatment of those under my guardianshi shall not be affected. I understand that I am voluntarily signing this form to release/request my health I Information to the party or parties designated. understand that Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable state laws may protect such Information.