Cancellation and Time Change Policy

Please make every effort to uphold your appointment; no-shows, cancellations, and running more than 15 minutes late make it harder for other patients to find care. If you must make changes, please cancel or reschedule within 24 hours of your appointment.

If you are more than 15 minutes late without notification your appointment will be canceled and rescheduled for the next available appointment time.

Any no-shows or appointments canceled and/or rescheduled online, in-person, or over the phone within 24-hours of the appointment will be charged the full appointment fee.

We appreciate your understanding and cooperation.

I understand that my appointment will need to be rescheduled should I arrive after the scheduled start time and I will incur a cancellation fee in the amount of the full appointment. This fee also applies to appointments canceled or rescheduled within the 24 hour window:

Office Policy

This agreement document contains important information about our professional services and business policies. It also contains summary information about HIPPA, the Health Insurance Portability and Accountability Act, a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your PHI, Protected Health Information, used for the purpose of treatment, payment, and health care operations. HIPPA requires that we provide you with the Notice of Privacy Practices, which is enclosed. Your signature is required by law on the agreement as well as the Acknowledgment of Receipt form. Although these documents are long and sometimes complex, it is important that you read them carefully. When you sign this document, it will represent an agreement between us. You may revoke the agreement in writing at any time. The revocation will be binding unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer to process or substantiate claims under your policy, or it you have not satisfied any financial obligation you have incurred.

IV CENTER PHONE AND VOLUME POLICY

We kindly request that you refrain from cell phone use inside the IV Center. As a courtesy to others please silence your cell phones. If you need to talk on the phone please step outside or request a private room if available. We aim to provide a tranquil and relaxing environment for our patients, so please keep cell phones on silent, bring headphones, and refrain from loud conversations while in the IV Center.

GUARANTEE OF PAYMENT?ASSIGNMENT OF INSURANCE BENEFITS

Unless otherwise stated. I understand that fees are due for any services rendered on the date of service. I authorize payment for services rendered to me to be made directly to this office for benefits otherwise payable to me. These payments shall not exceed the regular charges for this period of treatment. I also understand that is out of network with all insurance and it is my responsibility to submit to my insurance company. I understand that I am responsible for checking and knowing what my coverage is for out of network providers.

HOW OFTEN CAN I EXPECT TO HAVE AN APPOINTMENT?

Doctors/Clinicians may choose to see you as frequently as once or twice per week, depending on the nature of the problem. In the later phases of treatment, appointments are typically scheduled less frequently. Sessions are 15 minutes or longer. Occasionally, where families are involved, longer sessions may be scheduled. Every effort will be made to schedule sessions at times that are convenient for you.

HOW MIGHT I REACH YOU IF I FEEL A NEED?

Although the telephone is not a good substitute for talking face-to-face, there may be times when calling makes good sense. Clients occasionally need to speak with me between sessions. You will know intuitively if that that is the case, and brief telephone consultations are more than welcome. To make or change an appointment, please call us directly. Messages are checked daily unless otherwise specified.

WHAT HAPPENS IF AN APPOINTMENT IS MISSED?

Coming regularly and on time is an indication of your commitment to the therapeutic process. Once an appointment is made, that time is set aside for your use. Late cancellations frequently preclude making an appointment available to another client. Any cancellations for any appointments must be received 24 hours before or by noon on Friday for any Monday appointments. You will be charged in full for any missed or late cancellation appointments. Remember that scheduling an appointment means that it will be held only for you, and therefore, cannot be used by another person.

HOW CONFIDENTIAL ARE SESSIONS?

The various laws of the State of Illinois ensure that conversations you have with your doctor or clinician will be held in the strictest confidence. No information about you or the issues you discuss will be shared with anyone without your permission in writing, except as noted below: Doctors/clinical psychologists/therapists are obligated to share information given to them in confidence if they have reason to believe that a client is: 1) likely to inflict bodily harm on someone; 2) likely to harm herself or himself; 3) suspected of, or involved in, child or elder abuse; 4) or psychological decompensating of an individual to the point they can no longer care for themselves.

A court can demand a clinician to testify when there is a just cause as deemed by the judge. Other legal proceedings (such as workers' compensation claims, criminal proceedings, competency hearings, etc.) as well as your own submission of a claim to your insurance company, may require a clinician to release information with a release signed by you.

WHAT TO DO IN THE EVENT OF AN EMERGENCY:

In the event of an emergency, call us first and we will try to help. If we are not able to return your call as soon as you need, you may 1) call your family doctor, 2) call 911, or 3) go to your nearest emergency room if you are in appropriate condition to do so.

WHEN IS IT TIME TO END TREATMENT?

We believe that how long you remain in treatment is a matter left in your hands. It is important that you feel comfortable in raising the topic at any time. Clients often know intuitively when it is time to "move on." However, sometimes clients may wish to end treatment prematurely because they are experiencing a temporary relief of their symptoms without having dealt with underlying issues. At other times, clients may wish to end treatment because dealing with the issues that brought them into treatment is very painful. Whatever the reasons, ending treatment is an integral part of the treatment process and deserves to be dealt with thoroughly. Because of the importance of the therapeutic relationship, however, we hope that the decision to end treatment will be candidly discussed in advance. Rest assured that we will raise the topic when we believe your best interest would be served by reducing the frequency of your sessions or ending treatment.

WHAT ARE MY RESPONSIBILITIES?

Clients are expected to pay in full at the time of visit. Sessions will be billed based on time. Telephone calls will be billed based on a pro-rated fee if deemed necessary. The fee for all services varies. This includes printed materials, reports, letters, consultations, travel time for "out of office" services, and telephone calls. You will be billed for all time spent with you or on your behalf. Any special financial arrangements regarding payment, need to be in writing and signed by our office and the client/responsible party, be dated, and on file with our office in order to be considered valid. If your financial situation changes during the course of treatment and you find yourself unable to afford the services of a private practitioner, please discuss the matter with us and we can explore the options open to you.

BILLING STATEMENTS:

Payment at the time of service is required or prior to telemed visits and a statement will be provided for insurance and/oryour own personal records upon request. However, statements for balances remaining andthose that must be submitted directly to the insurance company are sent out monthly. If you losea statement or need additional assistance with your insurance filing please call the office andwe will attempt to assist you.

PAST-DUE BALANCES & COLLECTION SERVICE:

makes an effort to provide all patients with education and information regarding proposed and completed treatment as well as the costs associated, in order for each patient to make an informed decision regarding their treatment. In the event that I do not pay outstanding balance(s), I understand that 12% interest rate will be applied to any past due balances on my account(s). I also understand that should my past due balance be referred to an attorney or collection agency, I will be financially responsible for any additional costs incurred such as attorney fees, collection agency fees, court costs, etc.

PAYMENT:

Payment is due at the time of service or prior to telemed visits.

TAX RECORDS:

Keep a second copy for your own records. Depending on your financial circumstances and your total medical costs for any given year, treatment may be a deductible expense. Retaining a second copy of statements for your own tax records will help you to compute the feasibility of an income tax deduction at the end of the year.

ETHICS AND PROFESSIONAL STATEMENTS:

As doctors/clinicians, we try our best to uphold the most responsible, ethical, and professional standards possible, and we are accountable to you. If you have any questions or concerns about your course of contact with us, please discuss these issues with us directly. In signing this contract, you are agreeing that should you have any dissatisfaction or concerns about your treatment, or should you wish to contract with another psychiatrist/clinician for services, that you will do your best to indicate that you are making the change and why you wish for the change to be made. If you are unhappy with your services here and need help finding additional or alternative assistance, we will do our best to help you locate a more suitable referral or treatment source.

PATIENT DISMISSAL:

Our practice takes pride in our services and in the relationships with our patients who believe in quality care. Cooperation is a key element to successful treatment. reserves the right to dismiss patients in the interest of customer service and quality care for all patients. will be happy to transfer patient records to another provider at the request and approval for any patients who are dismissed.

QUESTIONS:

If during the course of your treatment, you have any questions about the nature of your treatment (i.e. goals, procedures, etc.) or about your billing statement, please ask.

A FINAL WORD:

The therapeutic relationship is a very personal and individualized partnership. We want to know what you find helpful and what, if anything, may be getting in the way. Periodically we will discuss your progress. Clients often know intuitively the kind of help they want. We want you to feel free to share with us what we can do to help.

PLEASE ASK BEFORE SIGNING BELOW IF YOU HAVE ANY QUESTIONS ABOUT ANY TREATMENTS OR OUR OFFICE POLICIES. YOUR SIGNATURE INDICATES THAT YOU HAVE READ OUR OFFICE POLICIES AND AGREE TO ENTER TREATMENT UNDER THESE CONDITIONS. FURTHER, IT INDICATES YOUR UNDERSTANDING THAT WE MAY TERMINATE YOUR TREATMENT IF YOU DO NOT COMPLY WITH THE POLICIES OR WE FEEL YOU ARE NOT BENEFITING FROM TREATMENT.

I HAVE READ THIS POLICY AND AGREE TO ABIDE BY IT.

HIPPA Privacy Authorization Form

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

I have been and always will be totally committed to maintaining client's confidentiality. I will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.

This notice describes office policies related to the use and disclosure of your healthcare information.

USES AND DISCLOSURES OF YOUR HEALTHCARE INFORMATION FOR THE PURPOSE OF PROVIDING SERVICES:

Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality healthcare. State and federal laws allow us to use and disclose your healthcare information for these purposes.

TREATMENT:

I may need to use or disclose health information about you to provide, manage, or coordinate your care or related services. Coordination of care might include consultations and potential referral sources.

PAYMENT:

Information needed for billing and collection purposes. I may bill the person, who has signed for financial responsibility.

HEALTHCARE OPERATIONS:

I may need to use information about you to review our treatment procedures and business activity.

Information may be used for certification, compliance, and licensing activities.

OTHER USES OR DISCLOSURE OF YOUR INFORMATION, WHICH DOES NOT REQUIRE YOUR CONSENT:

These are some instances where I may be required to use and disclose information without your consent.

For example, but not limited to: information you and/or your child report about physical or sexual abusethen by state law, we are obligated to report this to the Department of Children and Family Services; If you inform me that you are in danger of harming yourself or others; Information to remind you of/or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.

CLIENT RIGHTS

RIGHTS TO REQUEST HOW WE MAY CONTACT YOU:

It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc. Sometimes we may leave messages on your voicemail. You have the right to request that our office communicate in a different way. Please Select one:

RIGHT TO RELEASE YOUR MEDICAL RECORDS:

You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we have acted in reliance on such authorization.

RIGHT TO INSPECT AND COPY YOUR MEDICAL AND BILLING RECORDS:

You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the clinic directly. Under limited circumstances we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing, and/or supplies.

RIGHT TO ADD INFORMATION OR AMMEND YOUR MEDICAL RECORDS:

If you feel that information contained in your medical records is incorrect or incomplete, you may ask us to add information to amend the record. We will make a decision on your request within 60 days, or some cases within 90 days. Under certain circumstances, we may deny your request to add or amend information. If we deny your request, you have the right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the clinic directly. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

RIGHT TO ACCOUNTING AND DISCLOSURE:

You have the right to request an accounting of disclosures, if any, which is a list of certain disclosures such as child or elder abuse, disclosures related to suicidal or homicidal threats, disclosure to the U. S. Department of Health and Human Services to evaluate compliance.

RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF YOUR HEALTH INFORMATION:

You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to the clinic directly. However, we are not required to agree to such a request.

RIGHT TO COMPLAIN:

If you believe your privacy rights have been violated, please contact the clinic directly, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.

RIGHT TO RECEIVE CHANGES IN POLICY:

You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from your doctor/clinician or the office staff.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice describes our practices and

• Any health care professional authorized to enter information into your chart.
• Any member of a volunteer group we allow to help you while you are in the office.
• All employees, staff and other personnel.

All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and 1ocations may share medica1 information with each other for treatment, payment or health care operations purposes described in this notice.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the office, whether made by office personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private (with certain exceptions);
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information about You

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

At Your Request

We may disclose information when requested by you. This disclosure requires a written consent.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, or other office personnel who are involved in taking care of you at the office. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. The office also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the center who may be involved in your medical care after you leave the office, such as ski1led nursing facilities, home health agencies, and physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.

For Payment

We may use and disclose medical information about you so that the treatment and services you receive at the office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the office so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside the office who are involved in your care, to assist them in obtaining payment for services they provide to you.

For Healthcare Operations

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.

Treatment Alternatives

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services

We may use and disclose medical information to tell you about our healthcare-related products or services that may be of interest to you.

Fundraising Activities

We may use medical information about you, or disclose such information to a foundation related to the office, to contact you in an effort to raise money for the office and its operations. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the office. If you do not want the office to contact you for fundraising efforts, you must notify the office administrator in writing.

Office Directory

We may include certain limited information about you in the office directory while you are a patient at the office. This information may include your name, location in the office, your general condition (e.g., good, fair, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This information is released so your family, friends and clergy can visit you in the office and generally know how you are doing.

To Individuals Involved In Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the office.

In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, we are required to attempt to contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office.

If you have any questions about our Notice of Privacy Practices, please contact the practice administrator.

I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility

Payment for services is expected at time of service. We accept all major credit cards for all transactions. The credit card will be charged following each session with no prior notification required. A receipt is available upon request. By signing below you are acknowledging that you will provide form of payment prior to your scheduled appointment.