Insurance & Payment Contract

- I authorize release of information to all my insurance companies. 

- I understand that information I give my doctor will be kept confidential, but my doctor is required by law to report evidence of child abuse.

- I understand that I am responsible for my bill. 

- I understand that I am responsible for payment for any and all missed session for which I do not notify office for of the cancellation at least 24 hours in advance   cancellation fee will be charged as 

 Doctors  $80.00 

Nurse Practitioner in Psychiatry $60.00

 Therapist $75.00

PATIENT ACKNOWLEDGEMENT

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Private Mental Health Group, LLC 

CONSENT TO EMAIL USE

As a supplement to your in-office appointments, we are inviting you to use email to communicate with our practice. Set forth below are policies outlining when and how email should be utilized to maintain your privacy and to enhance communication as well as a place for you to acknowledge your consent to its use. Your decision to utilize email is strictly voluntary and your consent may be rescinded at any time. Email will be accessed by Private Mental Health Group clinical provider or a staff member on a regular basis. You may expect any required response within 24 hours. 

When may I use email to communicate with the office?

Email may be used to:

• Appointment requests.
• Other matters not requiring an immediate response. 

When should I NOT use email to communicate with the office?

Email should never be used:

• In an emergency.
• I you are experiencing any desire to harm yourself or others.
• If you are experiencing a severe medication reaction. 
• If you need an immediate response. 

What are the risks of using email?

Risks of communicating via email include but are not limited to:

• Email may be seen unintended viewers if addressed incorrectly.
• Email may be intercepted by hackers and redistributed. 
• Someone posing as you could access your information. 
• Email can be used to spread computer viruses.
• There is a risk that email may not be received by either party in a timely matter as it may be caught by junk/spam filters. 
• Emails are discoverable in litigation and may be used as evidence in court. 
• Emails can be circulated and stored by unintended recipients.
• Statements made via email may be misunderstood thus creating miscommunication and/or negatively affecting treatment. 
• There may be an unanticipated time delay between messages being sent and received. 

What happens to my messages? 

• Emails will be printed out and maintained as a permanent part of your medical record. 
• As part of your permanent record, they will be released along with the rest of the records upon your authorization or when the doctor is otherwise legally required to do so.
• Messages may be seen by staff for the purpose of filing or carrying out requests (e.g., appointment scheduling).

What happens to my obligations?

• I must let the doctor know immediately if my email address changes.
• If I do not receive a response from the doctor in the time frame indicated (stated expected response time), I will contact him/her by telephone if a response is needed.
• I will use email communication only for the purpose stated above.
• I will advise the doctor in writing should I decide that I would prefer not to continue communicating via email.
• I understand that the email may not only be used to supplement my appointment with the doctor and not as a substitute for them.
• To avoid possible confusion, I will not use internet slang or short-hand when communicating via email.

What steps has Private Mental Health Group, LLC taken to protect the privacy of my email communication? 

• Set up a password-protected screen-saver on his computer.
• Educated staff on the appropriate use and protection of email. 
• Does not access patient email from public Wi-Fi hotspots.
• Will not transmit highly sensitive information via email.
• Will not forward patient email to third-parties without your express consent.
• Will verify email addresses before sending messages. 

What steps can I take to protect my privacy?

• Do not use work computer to communicate with the doctor as your employer has a right to inspect emails sent through the company's system.
• Do not use a shared email account to transmit messages.
• Log out of your email account if you will be away from your computer.
• Carefully check the address before hitting "send" to ensure that you are sending your message to the intended receiver.
• Avoid writing or reading emails on a mobile device in a public place.
• Avoid accessing email on Wi-Fi hotspot.
• Make certain that your email is signed with your first and last name and include your telephone number and date of birth to avoid possible mix up with same or similar names. 

CRASMERE WEEKLY NEWSLETTER

Our goal is to start a newsletter that allows patients to be more informed with our offices. This newsletter will be emailed to you, under HIPPA regulations and your information will be kept in complete confidentiality. If you subscribe to this newsletter and decide at a later date that you do not wish to receive it any longer, you can simply unsubscribe to it. Please write your information below, with your signed consent, printed name and we will send you your newsletter. 

I am aware that I will be fully financially responsible for my or my child's services at Private Mental Health Group, LLC if I don’t comply with any of the following:

Fail to notify that my policy has changed.

Fail to inform that I have more than one active policies at the time of the visit.

Fail to inform Private Mental Health Group about start date of collecting SSD benefits.

Fail to inform Private Mental Health Group about the start date of Medicare coverage.

Fail to inform Private Mental Health Group that my Medicare coverage has been changed to HMO.

Fail to inform Private Mental Health Group that my coverage changed to Fidelis or Mediblue.

Fail to inform Private Mental Health Group about divorce and elimination of my benefits under my ex spouse.

I understand that if my medical policy is retroactively terminated for any reasons, I am the one responsible for my payments to Private Mental Health Group, LLC