Second-Opinion Consultation Packet - Dr. Gimbel

1. Overview

This is a one-time consultation, not the beginning of a treatment relationship. It is designed to provide an independent psychiatric opinion, based on review of available records and a clinical interview.

This consultation may help clarify:

• Diagnosis
• Treatment strategy
• Medication options
• Clinical formulation

It is most appropriate for individuals seeking a clear, time-limited evaluation with no ongoing treatment relationship.

2. What’s Included

This consultation includes:

• One 90–120 minute session
• Review of submitted documentation (prior evaluations, treatment summaries, relevant collateral)
• A written summary with impressions and recommendations
• Optional sharing of the summary with your treating provider

3. What’s Not Included

This is not a pathway into ongoing care. The consultation does not include:

• Prescriptions or medication management
• Messaging after the consultation
• Crisis or after-hours availability
• Completion of forms (FMLA, accommodations, disability, legal, insurance, etc.)
• Informal follow-up questions or clarifications
• Continued ongoing treatment at North Star Behavioral Health

4. Records and Preparation

If you would like records reviewed before the visit, they must be submitted at least 3 business days in advance.

This may include:

• Prior psychiatric, psychological, or neuropsych evaluations
• Medication history
• Notes from other providers
• School, occupational, or legal documentation

Documents should be sent via secure upload or encrypted email. Late or incomplete records may not be reviewed.

5. Written Summary

You will receive a written consultation summary following the session.

This includes:

• Diagnostic impressions
• Treatment recommendations
• Clinical observations

The summary is clinical only and not designed for legal or forensic use. You may request to have it sent directly to your treating provider.

6. Fee and Payment

The consultation fee is $2,000.

This includes:

• Preparation and record review
• The consultation session
• Written summary

Full payment is due at the time of scheduling.

We do not participate in insurance networks. Upon request, we can provide a paid statement (superbill) for your use in seeking reimbursement.

7. Good Faith Estimate (GFE)

In accordance with the No Surprises Act, you are entitled to a Good Faith Estimate of expected charges.
 
Service: One-time second-opinion psychiatric consultation
CPT Code: 90792
Estimated Total Cost: $2,000

This is a self-pay service and will not be billed to insurance. You are responsible for full payment at the time of scheduling.

If you are billed more than $400 above this estimate, you may dispute the bill. For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

8. Cancellations

• Cancellations made more than 5 business days in advance will be refunded in full
• Cancellations made within 5 business days of the scheduled session are non-refundable
• If records are not received in time, the consultation will proceed based on interview alone

9. Communication

• All communication occurs before the visit (scheduling, logistics) or during the visit itself.
• There is no messaging, follow-up, or continued contact after the consultation.
• This consultation does not include emergency services. If you are in crisis, please contact your current providers, call 911, or go to the nearest emergency room.

10. Telehealth Appointments (If Applicable)

Consultations may be conducted via video if not held in person. We use a HIPAA-compliant telehealth platform.

Telehealth Consent:

I understand that this appointment will occur by videoconferencing or telephone, and that it differs from an in-person visit. I understand the potential risks, including technical interruptions and unauthorized access, and that reasonable safeguards are in place. I agree to receive care via telehealth and understand I will be billed at the same rate as an in-person consultation.

Telehealth is subject to state licensing laws and may only be offered in jurisdictions where Dr. Gimbel is licensed to practice.

11. Digital Scribe Consent (Required)

Dr. Gimbel uses a secure, HIPAA-compliant AI-assisted digital scribe during all sessions. This tool supports accurate documentation, minimizes in-session typing, and helps ensure timely clinical notes.

• The scribe listens silently via encrypted connection
• No audio is stored or saved
• Dr. Gimbel reviews and edits the note before finalizing
• The scribe does not replace clinical judgment or make any treatment decisions

Consent to use the digital scribe is required to proceed with the consultation.

12. Consent and Acknowledgement

 

By signing below, I acknowledge that I have read, understood, and agree to all policies above:

Notice of Privacy Practices (Effective as of 1/1/2024)

This notice describes how medical information about you may be used and disclosed and how you can get access to that information.  Please review it carefully.

Our Responsibilities:
North Star Behavioral Health is required by law to maintain the privacy and security of your protected health information.  We will not use or disclose your health information other than as described here unless you provide written authorization.  You may revoke your authorization at anytime, in writing, but only as to future uses or disclosures and only where we have not already acted in reliance on your authorization.

(For additional information: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html)

We are required by law to provide you with this Notice of Privacy Practices.  This Notice describes how we use your health information and disclose it with others.  We must abide by the terms of this Notice currently in effect.  We reserve the right to change the terms of our Notice and to make the new Notice provisions effective for all health information that it maintains.  We will review this policy with all existing patients and all new patients.

Uses and Disclosures:
The following are the types of uses and disclosures of your protected health information that we are legally permitted to make:

A.     Treatment:
We may use and disclose your protected health information to provide treatment, to coordinate care, or to manage your healthcare and other related service by sharing it with other professionals, including covering physicians.  Example: We discuss your medication treatment with your primary care physician.
B.     Payment:
We can use and share your health information, as needed, to bill and obtain payment for my health care services from health plans or other entities.  Example: We give information to your health insurance plan for prior authorization of a medication.
C.     Healthcare Operations:
We may use or disclose your health information in order to conduct the business of providing healthcare, to improve your care, and to contact you when necessary.  Example: quality assessment and improvement activities.
D.     Business Associates:
We may disclose your health information to third-part business associates that perform activities or services on our behalf.  Example: We may use or disclose your health information to a business associate that we use to provide reminders to you of upcoming appointments.

Other Permitted Uses and Disclosures:
In addition to the above permitted uses and disclosures, the following are circumstances in which we are either allowed or required to disclose your health information without your authorization, consent, or opportunity to object (For additional information: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html):

A.     Required by Law:
We may share information about you to the extent that it is required by local, state, or federal laws under the circumstances provided by such law.  This includes with the Department of Health and Human Services if it wants to see that we are complying with the federal privacy law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

B.     Health Oversight Activities:
We may use or disclose your health information to state agencies and federal government authorities, or to a health oversight agency, for activities authorized by law such as audits, administration or criminal investigations, inspections, licensure, accreditation or disciplinary action and monitoring compliance with the law, including in order to determine your eligibility for public benefit programs and to coordinate delivery of those programs.  The Illinois Mental Health and Developmental Disabilities Confidentiality Act allows for the uncontested disclosure of your health information to a health information exchange, which oversees the electronic exchange of health information.

C.     Public Health and Safety:
We may disclose your health information for public health activities, including: to prevent or report communicable diseases; to report births and deaths; to report reactions to medications or problems with products; to notify a person who may have been exposed to a communicable disease, or may be at risk for contracting or spreading the disease.

D.     Research:
We may use or disclose health information for research that is approved by an Institutional Review Board when written permission is not required by federal or state law.  This may include preparing for research or informing you about research studies in which you might be interested.

E.     Serious Threat to Health or Safety:
We may be required to use and disclose your health information to prevent or lessen a serious threat to a person’s or the public’s health or safety.  If you present a clear and present danger to yourself and refuse to accept the further appropriate treatment, and we have a reasonable basis that you can be committed to a hospital, then we must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.  If you communicate to us an explicit threat to kill or inflict serious bodily injury upon an identified person or persons, and you have the apparent intent and ability to carry out the threat, then we must take reasonable precautions.  Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization.  We must also do so if we know you have a history of physical violence and we believe there is a clear and present danger that you will attempt to kill or inflict bodily injury on this person or persons.

F.      Legal Proceedings:
We may be required to disclose health information in the course of any judicial or administrative proceeding in response to a legal order or other lawful process, including a subpoena, to the extent that such disclosure is authorized and permissible under the Illinois Mental Health and Developmental Disabilities Confidentiality Act.

G.     Law Enforcement:
We may be required to disclose health information for law enforcement purposes.

H.     Worker’s Compensation:
We may use and disclose your health information as required to comply with worker’s compensation laws and other programs that provide benefits for work-related injuries or illnesses.

I.       Coroners, Funeral Directors, and Organ Donation:
We may be required to disclose health information to a coroner or medical examiner to identify a deceased person or to determine the cause of death.  We may also disclose health information to a funeral director or their designee, as necessary to carry out their duties.  Your health information may also be disclosed to organizations that facilitate organ, eye, or tissue donation or transplantation.

 

Your Individual Rights:
Although your medical record at our office is our property, your health information that it contains belongs to you.  The following is a statement of your rights with respect to your health information, including a brief description of how you may exercise these rights:

A.     You have the right to inspect and to request a copy of your medical record.
At any time, you may inspect and obtain a copy of health information about you, including your medical and billing record, which may be used to make decisions about your care.  All requests to access your record must be made in writing to North Star Behavioral Health and will be processed within 30 days.  If you request a copy of your records, we may charge you a reasonable, cost-based fee.

B.     You have the right to request an amendment to your medical record.
You may request that we amend your treatment and billing information if you believe the information is incorrect or incomplete, for as long as we maintain the information.  If for some reason we deny your request, we will give you a written statement within 60 days with the reasons for the denial, as well as what other steps are available to you.

C.     You have the right to request confidential communications.
You can ask us to contact you in a specific way (e.g., by cell phone or home phone) or to send mail to a different address.  We will make every effort to accommodate requests, provided you supply a valid alternative address or other method of contact.  In certain cases, we may need to contact you and may do so at the original address or phone number if attempts to contact you at the alternative locations are not successful.

D.     You have the right to request a restriction on certain uses and disclosures.
You can ask us to not use or share certain health information for treatment, payment, or practice operations.  We are not required to agree to your requested restriction.

E.     You have the right to obtain an accounting of disclosures of your health information.
This right applies to disclosures for purposes other than treatment, payment, of healthcare operations as described above in this Notice.  It does not apply to disclosures we may have made to you, that are authorized by you, information provided to family members or friends about your care, or for notification purposes.

F.      You have the right to obtain a paper copy of this notice.
If you would like a paper copy at any time, please ask and we will provide you with a copy promptly.

G.     You have the right to file a complaint.
If you believe that North Star Behavioral Health has violated your privacy rights, please communicate to us your concerns by contacting Dr. Brandon Gimbel at the office location.  You may also send a written complaint to the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue, S.W., Room 509F, Washington, D.C., 20201.  You may also call this office at 877-696-6775.  For further information: http://www.hhs.gov/ocr/privacy/hipaa/complaints/

You may contact North Star Behavioral Health for further information about the complaint process or privacy practices:

North Star Behavioral Health
601 Skokie Blvd, Suite 1-A
Northbrook, IL, 60062
Phone: 847-892-7300
Fax: 888-892-7301

Notice of Privacy Practices Acknowledgement

I understand that, Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.  I have received, read, and understood your Notice of Privacy Practices, containing a more complete description of the uses and disclosures of my health information.  I understand that North Star Behavioral Health has the right to change its Notice of Privacy Practices from time to time and that I may contact North Star Behavioral Health at any time to obtain a current copy of the Notice of Privacy Practices.

By signing below, I acknowledge that I have read, understood, and agree to all policies above:

After signing below, please check your welcome email for a separate link to authorize your payment method.

This step must be completed before your appointment.