CONSENTS AND AUTHORIZATIONS

CONSENTS AND AUTHORIZATIONS

Patient Name: *

Email: *

example@example.com

Phone Number: *

Area Code Phone Number

Authorization for Release of Information

I hereby authorize Boulder Mind Care to exchange any information necessary regarding the patient with other health care practitioners in the care of the patient. These communications of information may involve unencrypted electronic communications by email, phone, text messages, and voicemail as well as fax. These communications may include protected health information and other confidential information. This authorization to obtain and release information is valid until revoked. The undersigned may revoke this consent in writing at any time, except with regard to information that has already been shared or disclosures that have already been made in reliance on such consent.

Electronic Communications Authorization

I hereby authorize Boulder Mind Care to communicate with me using electronic communications including email, text messages, and voicemail. I may be contacted using the numbers or addresses that I have provided to Boulder Mind Care, or that I have used to initiate contact with Boulder Mind Care. These communications may include appointment information, as well as protected health information and confidential information. I understand that these electronic communications are not encrypted.

Acknowledgment of Privacy Practices Notice

I have reviewed the Notice of Privacy Practices at

https://bouldermindcare.com/privacy-policy

I acknowledge that a copy of the Privacy Policy is available to me upon request.

Financial & Appointment Policies/Agreement to Pay

I have reviewed and agree to the Boulder Mind Care's policies regarding appointment scheduling and payment at

https://bouldermindcare.com/financial-policy

I understand that I am directly responsible for all charges incurred for medical services for the patient.

With my signature below, I affirm: 1) that I understand and agree to Boulder Mind Care's above policies; and 2) that Boulder Mind Care does not accept insurance or any third-party payor, a) the one-time fee for record review, collection, phone calls with your other providers, and the initial consultation is $390, b) ketamine infusions for mental health are priced at $690 per infusion, c) and that ketamine infusions for chronic pain are $1,500 per infusion. *

Date *

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