Patient Consent For Services

Please initial that you have read and understand the following

Consent to Receive Services

I am giving consent to receive psychotherapy services from Roene Zohler MSW, LCSW ___

I have received a copy of Understanding Your Health Records ___

I have received a copy of Client Rights & Responsibilities ___

I understand that my personal information may be transferred electronically ___
(i.e. online billing, email, fax machine).

You can email me about upcoming workshops, seminars, appointment reminders. Yes __ No __

My email address is:___________________________________________________

Financial Agreement

I understand that I am responsible for paying for services rendered. If I am using

the sliding fee schedule based on income to determine my fee, I agree to notify

Roene Zohler of any changes in my income. ___

I understand that when I schedule an appointment I am reserving a period of

time, therefore, I will be charged a $50.00 fee if I do not cancel an appointment at

least 24 hours in advance and I will be charged the full fee if I do not show for

an appointment without giving notice. ___

I understand that a collection agency may be utilized to recover unpaid debt and if this

became necessary my private information would be disclosed to the collection agency.

If this action is necessary, I will receive a written notification of intent to release

information to the collection agency with a time period to make alternate arrangements. ___

IF YOU ARE USING YOUR INSURANCE PLEASE READ AND INITIAL

I understand that it is my responsibility to know what my insurance benefits pay for, how many

sessions are covered under my plan and what services are not covered. I understand that I am

financial responsible for services if my insurance company does not pay for the service

rendered. As a courtesy, Roene Zohler may submit a claim for services to my insurance company.

I hereby give permission to do so. ___

I understand that my insurance company may require the release of my personal information to

them and to my Primary Care Physician as a condition of paying for the service. Choosing to

use my insurance benefits is consent to release this information. I understand that if I do not

want this information shared with my insurance company or my primary care physician I can

elect to pay for the service myself. ___

Primary Care Physician name:______________________________________________________

Address_______________________________ city___________ State____ Zip______________

Phone number_______________________ Fax Number _________________________________

Client or client representative signature: ____________________________________________

Date: _________________________

Witness signature_____________________________ Date ________________________

Complete this section if you plan on using your insurance to pay for services. Please note that the majority of insurance carriers reserve the right to access your records as a way to ensure proper utilization and treatment. In most cases, your insurance policy and my agreement with them allows for this record review. If you do not want your personal information shared with your insurance company you can elect to pay for services yourself.

Primary Insured _______________________________________________________

Primary Insured date of birth and SSN: _____________________________________________________

Insurance Company Name: _______________________________________________________________

Insurance Company Address: ____________________________________City______________________

State _____ Zip ____________ Phone ______________________________

ID#: _____________________ Group#: ____________________

Authorization: ____________________

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