This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (patient's) written permission, except where disclosure is required by law. For example, if you (patient) express intent to harm yourself or others or indicate abuse of a child or elder. Please refer to the provisions explaining when the law requires disclosure described to you in the Notice of Privacy Practices (included with this packet).
HEALTH INSURANCE AND CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier in order to process the claims. If you so instruct, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly the Treatment Notes will not be disclosed to your insurance carrier. Dr. Mesirow has no control or knowledge over what the insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies' computers and soon will be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies' computers or the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access.
CONSULTATIONS: At times, Dr. Mesirow consults with other professionals regarding her patients; however the patient's name and other identifying information is never mentioned. The patient's identity remains completely anonymous and confidentiality is fully maintained. If Dr. Mesirow is consulting with other professionals treating the same patient, a release of information is always obtained before any contact is made or information about the case is discussed.
PAYMENTS & INSURANCE REIMBURSEMENT: Patients are expected to pay the standard fee of $150.00 per session. Dr. Mesirow will bill your insurance company accordingly. If your insurance company denies payments submitted, you agree to pay for services rendered.
TELEPHONE AND EMERGENCY PROCEDURES: If you need to contact Dr. Mesirow between appointments, please leave a message on her voicemail service (951.775.4057) and your call will be returned as soon as possible. Dr. Mesirow checks her messages a few times each day, unless she is out of town. If an emergency situation arises, please indicate it clearly on the message. If you need to talk to someone immediately, please call 911.
EMAIL/TEXT: Please sign here if I have your permission to contact you via email or text and/or to respond to emails or text messages you may send to me. Please remember that email is not HIPAA compliant and is not guaranteed as a confidential way to communicate and I cannot guarantee confidentiality via Internet communications. Additionally, processing therapy information is not appropriate via email or text as this is best saved for your session. Email is for appointment scheduling or brief questions.
