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Please print and email completed form to drpaulettegorsuch@ymail.com
I the undersigned patient voluntarily consent to allow Dr. Gorsuch and her staff to provide assessment, evaluation and/or mental health treatment and to provide appropriate treatments she sees necessary as an outpatient or as the legal guardian of any minor outpatient on a continuing bases including being a Telemedicine patient over the internet as deemed necessary. I also understand the patient or guardian of the patient will be informed about the course of my treatment and I am free to terminate treatment at any time.
I hereby authorize Dr, Paulette A Gorsuch to release any mental health/behavioral information to my insurance company or its agents in order to secure payments. I certify that I have read and fully understand the forgoing. As the patient, the patient’s guardian, conservator or general agent. I agree to accept the above terms.
I understand that the patient is financially responsible for all charges, whether or not paid by the insurance company unless specifically exempted by my insurance Company ‘s separate contract with Dr.Gorsuch. It is the patient’s responsibility to know and understand their own insurance benefits. Dr Gorsuch will attempt to verify benefits, but she is not responsible for misinformation or interpretation of insurance benefits. The patient will be responsible for deductible-insurance, co-pays and noncovered services.
The patient will be responsible for all claims and to be responsible for all denied claims due to “No eligibility, “Non-covered services, or any Pre-authorization certifications not obtained. It is the patient’s responsibility to pay for any or all services already provided and no compensation has already been sent To Dr.Gorsuch by a third party.
This notice describes how medical health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I understand that under federal law (“Hippa”), the practice of Dr.Paulette Gorsuch LMFT may NOT release any mental health information to any individual, without my express written permission. Law enforcement and court orders are exceptions to this requirement.
In addition to my health insurance carrier, any third-party payor(s). I authorize Dr. Paulette Gorsuch to release mental health information to the following person(s)
Dr Gorsuch may use and disclose mental health records for the following purposes:
i. Treatment
ii. Payment
iii. Chart Auditing Purpose
iv. Court order
The right to revoke authorization in writing
The right to inspect and copy your protected health information
The right to receive an accounting of disclosure your protected health information
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