18425 NW 2nd Ave Suite 404B Miami Gardens, FL 33169

Phone: 305-549-8100 Fax: 786-565-3015  Website: www.rmhclinic.com

Please sign: Both signatures are necessary / am fully responsible for all payment for services rendered by the Doctors and or staff of Reflections of Health, Inc. not paid by my Medical Insurance Company.

I also give permission for this office to use a laboratory to process any test the Doctors and / or staff members of Reflections of Health, Inc deem it is necessary for as related to medical condition.

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT: (PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY)

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your Protected Health Information to carry out treatment and payment activities. Notice of Privacy Practice: You have the right to read our Notice of Privacy Practice before you decide whether to sign this Consent. Our Notice provides a description of our treatment payment activities and healthcare operations, of the uses and disclosures we make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will post in our office as well as issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Reflections of Mental Health, Inc. 18425 NW 2nd Ave Suite 404B Miami Gardens, FL 33169

Right to Revoke You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person / Department listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you revoke this Consent.

 

Right to refuse and/or terminate treatment at any time. Right to access and obtain a copy of your health information. Right to an accounting of disclosures made on your health information. Right to request an amendment to your health information. Right to request confidential communications. Request that we communicate with you about your health information at alternative

Right to restrict certain disclosures of your health information. Right to complain if you feel that we have used or disclosed your health information inappropriately. The right to know the ways in which Reflections of Mental Health, Inc uses and discloses your health information for treatment, payment, and health care operations. The right to authorize and revoke release of medical or health information.

I hereby certify and understand the above patient rights.

PLEASE READ, INITIAL, AND SIGN THE FOLLOWING INFORMATION CONCERNING THE POLICIES OF THIS OFFICE. YOU WILL BE GIVEN A COPY FOR YOUR RECORDS. A. INSURANCE PAYMENT ORDER:

I, (your name)hereby authorize Reflections of Mental Health Inc. to use my information when conducting business with my insurance company. I understand that my health information will be used, as needed, to obtain payment for my health care services from my insurance providers. This may include certain activities the Reflections of Mental Health, Inc. staff may need to undertake before my health care insurer approves or pays for health care services recommended for me; such as determining eligibility or coverage for benefits, reviewing services provided to me for medical necessity, and undertaking utilization review activities.

You are responsible for all co-payments and/or fees at the time of service, otherwise billing fees will be incurred. If another party is responsible for your payments, please let us know prior to your visit SO that we may make the

A fee of $35.00 will be charged for any return checks, along with a processing fee.

Appointments are scheduled according to each patient's needs and the availability of the physician. The time of your appointment is reserved for you. All cancellations and/or rescheduling of appointments MUST be done at least 24 hours in advance. Failure to call in advance to cancel their appointment will be considered a NO SHOW will incur a $25.00 cancellation/no show fee. Confirmation calls are done as a courtesy to patients; however, there are times we cannot make them. Please do not rely on our call.

MAINTAINING PATIENT STATUS:

In regards to mental health, it is very important that you be seen on a regular basis. At the end of each appointment, you will be given a follow-up appointment. It is recommended that you make the follow-up appointment before you leave our office in order to schedule the most convenient time for you. If you fail to keep and/or maintain follow-up appointments for a period of six month (180 days) or greater, we will conclude that you have terminated the patient-physician relationship and would no longer be an active patient.

TERMINATION OF CARE: Dr. Samuel reserves the right to terminate the patient-physician relationship if the patient is repeatedly noncompliant with treatment recommendations despite repeated redirection and use of available resources and/or inability to maintain a therapeutic relationship due to repeated conflicts or inability to maintain professional boundaries. The termination of care will be provided in writing via certified mail along with list of treatment providers.

 

No changes to medication or dosage will be done via telephone. All changes to treatment plan/medication regimen will be done via scheduled face-to-face visit either in office or secure video tele-psychiatry.

Your patient records are strictly confidential. For this reason, no information concerning you as a patient is released without your written consent. Disclosure of information to anyone such as another doctor, an attorney and/or a family member must be requested by written authorization by the patient. In an emergency situation when you, the patient, are at imminent risk of death or serious medical consequence; minimal, critically relevant information to assist in preventing dire medical consequences that may result if that relevant information is not released. In the case of a minor, their legal guardian must sign the authorization. The physician is legally bound to break doctor- patient confidentiality in cases of threat of harm to self or others, medical emergency, and in reports of child or geriatric abuse.

 

FMLA Forms/Medical Reports/Correspondence/Disability Forms While medical reports to insurance companies and employers are necessary for you to access benefits, they are not medically necessary for your treatment. Therefore, we charge for these additional tasks. Please allow 5 to 7 days for completion of your requests after we have all the appropriate releases and/or information to complete the forms. Paperwork is billed at $50 or more based on the complexity. No exceptions!!!!

In the case of a psychiatric emergency call 911 or go to your local emergency room. I have read and understand the information above.