VIDA SARKODIE INC

230 Route 206, Building 3, Suite 3, Flanders NJ 07836 Phone 973-298-0812 Fax 973-874-5194

2816 morris avenue, suite 22, Union, NJ, 07083 Phone 908-623-3365 Fax 908-623-3358

Please call to give card number to office. 

INSURANCE INFORMATION PRIMARY SECONDARY

PRIMARY  

SECONDARY

I hereby authorize my insurance benefits (e.g. Medicare & Madigan) to be paid directly to VIDA SARKODIE INC. I will accept financial responsibility for non-covered services. If my account is sent to a collection agency, I agree that I will be responsible for all collection costs. I also authorize the office to release information about services rendered by my provider(s) to my insurance carrier(s) and allow a photocopy of my signature to be used to file insurance claims.

Please call us during our normal business hours 9:00AM to 5:00PM at phone number 973-298-0812 If it is a serious emergency situation, do not leave a message in the voice messaging system. Please call back and contact a person. If the office is closed, you will be transferred to our answering service and will be able to talk to an attendant. Please note, we do not check our voicemail or messages when the office is closed or over the weekend and holidays.

If there is a delay in the call back and you are in a serious life-threatening emergency, immediately proceed to the following steps:

• Call 911. In some cases, and depending on the situation, you may call the police or try to reach your PCP, a friend, relative, or neighbor.
• Go to the nearest emergency room for immediate help. If you live close to our offices you may go to the emergency room at Saint Clare’s Denville Hospital.
• You may also call 973-625-6000 for psychiatric emergencies.

For regular appointments, please call us at least 1-2 weeks before you run out of your medications. On your regular visits, please inform us of any changes in your health, abnormal lab work, pregnancy or new medications prescribed by other doctors.

On each office visit, please make sure you have enough medication to cover you until your next visit and also over weekends and holidays.

Our office is no longer able to call/fax routine prescriptions to the pharmacy for renewals.

In case you cannot come for your scheduled appointment, please give us at least one to three business days' notice to call your pharmacy. As a courtesy, we will call your pharmacy to cover you until your next visit. Please note that we are unable to call any prescriptions over weekends, holidays, or after our normal business hours.

If you need to cancel/reschedule an appointment, we request a 24-hour notice. We do not authorize renewal of narcotics or controlled medications over the phone/fax at any time!

If you need to cancel/reschedule an appointment, we request a 24-hour notice. Our office will bill a sum of $50 for missed appointments.

To prevent being billed for unauthorized visits, please provide us with appropriate referrals, authorizations, and changes in your insurance information. Our secretary will gladly help you and provide information. If the office does not have your most current insurance information, you will be responsible for the services provided by the doctor.

For billing questions/problems, please contact 973-298-0812. If you are not satisfied with the response, contact the doctor directly.

LIMITS OF CONFIDENTIALITY:

Content of all therapy sessions are Considered to be Confidential. Both Verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the healthcare professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances: Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Insurance Providers (when applicable): Insurance companies and other thirty-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

I agree to the above limits of confidentiality and understand their meanings and ramifications.

related to my evaluation and treatment to the following:

The following topics have been discussed:

• Name and description of the medication
• Potential for interactions
• Risks and benefits
• Expected outcomes
• Potential complications
• Risks and precautions related to driving
• Risks of addictions, withdrawals, and weight gain
• Risks of falls and other accidents
• Reasonable alternative medications and alternative of NO medication
• In females, risks association with pregnancy and lactation. Please inform us immediately if you become pregnant.
• Risk of concomitant drinking or using other drugs.
• Risk of tardive
• dyskinesia Which may be a permanent condition (certain medications

I agree and consent to be treated by Vida Sarkodie or the covering doctor/nurse practitioner when not available.

I understand and give permission to the office to contact me for appointment reminders, billing/health concerns, and other matters.

I agree to allow the office to message, text, or email me.
I have been given the opportunity to ask questions about the information.
I agree to take the above medications.
I have discussed treatment options in emergency situations with the doctor.

Notice of Privacy Practices Patient Acknowledgement

I have received this practice's Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how may I exercise these rights, and the practice’s legal duties with respect of my information.

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice.

I understand I can obtain this practice's current notice of Privacy Practice on request.