INFORMATION FORM

COMMUNICATION / CONTACT

Timely and clear communication is key to a successful working relationship.  We have arranged three different ways that we can communicate with you/your legal guardian.  Please fill out information below ONLY for ways that you agree to be contacted.  We will ONLY contact the person listed below.  Please indicate your order of communication preference below:

By furnishing email above, I consent to contact through the “practice fusion” software (HIIPA compliant)

By furnishing my text# above, I consent to contact through the “OHMD” app  (HIIPA compliant)

As a courtesy to you, we have implemented an electronic appointment reminder system.  By furnishing your email above, you request/consent to the use of this email address for appointment reminders.

IMPORTANT POINTS TO REMEMBER

1. If you/your child are an imminent threat to self or others, call 911 or go to the nearest emergency room
2. Notify your provider if there are any significant changes to you/your child’s psychiatric or medical health
3. Do not email the practice with any urgent clinical matter.  Patients should discuss any clinical concerns directly with their provider.  Emails may be sent for administrative purposed after providing advanced verbal notice to our front office staff.
4. Please discuss with your provider before increasing, decreasing, or discontinuing any psychiatric medications.  Medication changes without consultation can be dangerous.
5. It is your responsibility to notify your provider if you are pregnant or plant to become pregnant
6. Refrain from driving if your medication makes you feel drowsy or otherwise impaired an notify provider
7. It is advised not to drink alcohol or use illegal substances while taking psychiatric medications.

I have read, understand and agree to the above important point to remember:

I, the undersigned, authorize Michael Rosen, M.D. and associates to charge my credit card for the following services or conditions:

• Missed appointments or cancellations not meeting the cancellation requirements
• Co payments (unless paid by check or credit / debit card at the time of the appointment)
• Any claim that is denied secondary to insurance being inactive at the time of service, or due to failure on the part of the patient or responsible party to obtain prior authorization or referral and / or complete forms required by the insurance company to process the claim (unless otherwise discussed and agreed by us)
• Any insurance claim that has not been covered (denied for any reason) by your insurance plan becomes YOUR responsibility 60 days after our proper initial filing of the claim
• The unpaid patient responsibility balance is due no later than 60 days after the date of service
• Any returned check for non sufficient funds plus a $60 fee
• $25 fee for completing any brief form/ letter
• $15 fee for medication refills between appointments
• $25 fee for any medication prior authorization that your insurance requires

Hereby authorize Michael Rosen M.D. to release /request (circle one or both) the following information and records obtained in the course of my diagnosis and treatment.  I understand that these records may contain confidential information about psychiatric treatment, substance abuse or dependency, sexuality, and communicable disease such at HIV/AIDS.

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

I understand that I have the right to refuse consent and signing of this authorization and that my treatment or the treatment of those under my guardianship shall not be affected.  I understand that I am voluntarily signing this form to release/request my health information to the party or parties designated.  I understand that information used for 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.

This authorization if effective immediately and shall remain in effect for one year from date of signing unless explicitly revoked in writing.

If Parent or Legal Guardian:

I have received and read the Michael Rosen, M.D. “Welcome Packet” (including our office procedures/policies, Notice of Privacy Policies and notice of my Rights with Respect to Health Information.  I understand and agree to all the policies.  I understand that I am responsible for all charges incurred for the above services, including those not paid by my insurance company.  I understand the policies are subject to change and these changes will be posted in the front office as well as on our website.  I understand it is my responsibility to keep abreast of all policy changes.  I consent to treatment including psychotherapy and /or medication management.  Any questions I have asked have been answered to my satisfaction.  My signature serves as acknowledgement and agreement to the above.

I have been provided with a copy of the Michael Rosen, M.D. privacy practices and HIPAA notice regarding the use and disclosure of PHI (protected health information) for treatment, payment and healthcare operations.  I understand these policies