I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. PD Mental Health Counseling of Queens County PLLC will honor contractual agreements made with those managed health care companies which stipulate specific reimbursement restrictions. Entiendo que soy responsable del pago de la cuota al inicio de cada cita. Estoy de acuerdo en ser responsable del pago total de los honorarios por los servicios prestados, independientemente de que el reembolso de la compañía de seguro ocurra.

I hereby authorize the release of necessary medical information for insurance reimbursement purposes. Por la presente autorizo la divulgación de información médica necesaria a efectos de reembolso de seguros.

I authorize the payment of medical benefits to the provider of services. Yo autorizo el pago de beneficios médicos para el proveedor de servicios.

I hereby consent to treatment by specified provider. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I am responsible, however, for any balance due prior to a decision to stop. Doy mi consentimiento para recibir tratamiento por un proveedor determinado. Entiendo que soy responsable de pagar cualquier saldo adeudado antes de la decisión de descontinuar el tratamiento.

You have the right to:

• Request, in writing, a restriction on certain uses and disclosures of your information.
• Request that communication of your health information be made by alternative means or at an alternative location.
• Request that you be allowed to inspect and copy your health record.
• Request that your health record be amended to correct incomplete or incorrect information.
• Request an accounting of disclosures of your health information as required by law.
• Revoke your authorization to use or disclose health information, except to the extent that action has already been taken.
• Request a paper copy of this notice.

Provider Duties:

• Maintain the privacy of your health information.
• Provide you with a notice as to legal duties and privacy practices.
• Abide by these terms of this notice.
• Notify you if unable to accommodate a requested restriction.
• Accommodate reasonable requests to communicate health information by alternative means.

My practice reserves the right to revise this notice and make a new notice effective for all protected health information maintained. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of the Department of Health and Human Services.

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian. Noted exceptions are as follows:

El contenido de todas las sesiones de terapia se consideran confidenciales. La información verbal y registros escritos no se pueden compartir sin consentimiento por escrito, con las siguientes excepciones:

1. I understand that my Therapist recommends engaging in telehealth services to provide treatment.
2. I understand that telehealth treatment has potential benefits including easier access to care.
3. I understand there is no guarantee that all treatment of all patients will be effective.
4. I understand it is my obligation to notify my Therapist of my location at the beginning of each session.
5. I understand it is my obligation to notify my therapist of any other persons in the location who can hear or see the session, and that I am responsible to ensure privacy at my location.
6. I understand that virtual assistant AI devices (Alexa, Echo, etc.) must be disabled during sessions.
7. I agree that I will not record the session without notifying my therapist and receiving agreement.
8. I understand there are potential risks including interruptions, unauthorized access, and technical difficulties.
9. I understand my therapist is not responsible for technological problems outside of their control.
10. I understand that I am responsible for information security on my own device and in my own location.
11. I understand that either I or my therapist can discontinue the telehealth consult if connections or protections are not adequate.
12. I understand the same fee rates apply for telehealth as for in-person treatment. I am obligated to contact my insurer to determine applicable co-pays. If insurance does not cover telehealth, I will be solely responsible for the entire fee.
13. To maintain confidentiality, I will not share my telehealth appointment link with anyone not authorized to attend.
14. I understand either I or my therapist can discontinue telehealth services if they do not appear to benefit me therapeutically.