Guarantor responsibility: Payment for all professional services rendered is the responsibility of the patient, parent, or guardian. Co-payments and all other payments for services are due when services are rendered. Dr. Litzinger is an in-network provider with most Blue Cross NC plans and most United Healthcare Plans. Please check with your insurance company prior to your visit to ensure coverage. If insurance issues arise, it is the responsibility of the Guarantor to contact the insurance company, group plan administrator, or employer representative for resolution. A patient's insurance policy is a contract between the patient and the insurance carrier.

 

At this time, Dr. Litzinger is conductioon his appointments via telehealth. 

Telehealth allows my doctor to diagnose, consult, treat and educate using

interactive audio, video or data communication regarding my treatment. I hereby

consent to participating in appoinments with Dr. Litzinger via telephone or the internet (hereinafter referred to as Telehealth)

I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Anyinformation disclosed by me during the course of my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of

child, elder, and dependent adult abuse and any threats of violence I may make

towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the

Telehealth interaction to any other entities shall not occur without my written

consent.

I understand that while psychotherapeutic and medical treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our appointments or other communication regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I mayhave regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications byproviding written notification to Dr. Litzinger.

I agree that I have read the information above.

This notice describes how medical information about you may be used and disclosed,and how you can gain access to this information. Please read it carefully and ask anyquestions if you are uncertain of the meaning of anything described below.

Your Rights

When it comes to your health information, you have certain rights. This explains your rights and some of our responsibilities.

You have the right to:

• Request a copy of your paper* or electronic medical records.

Electronic Record. On request, we will give you instructions on how to gain access to your electronic medical record. Your electronic medical record contains copies ofyour medication lists as well as some lab results.

*Written Therapy Records. Due the private nature of these records, we have a procedure to request a hard copy of your treatment records that requires you tomake a time to come in to our office to review the record at a time the doctor ispresent to answer any questions you may have. This policy is for the purposes ofkeeping your information private as well as for your understanding of the informationyour records contain. We will make every effort to accommodate your requestpromptly and as a time that is convenient to you. There are no exceptions to this policy.

Request Records be sent to another provider. With an signed Release of Information, we will send your records to another medical or psychiatric provider immediately.

• Correct your paper or electronic medical record (in writing). You can ask us to correct health information about you that you believe is incorrect or incomplete and we will address your request in writing within 60 days to explain if your request is possible or not.

• Request confidential communications. You can ask us to contact you in a specific manner for example, home, mobile, office phone or to send mail to a different address. Most often we are able to accommodate all reasonable requests.

• Ask us to limit the information we share. You can ask us to use or share certain health information for treatment, payment or insurance operations. We will always consider your privacy and will accommodate most general requests for limiting information however, in some cases for example, if we believe it will affect  your care, we may not agree to your request. For insurance purposes, claims to your insurance company will contain some private information but you can ask us not to submit claims on your behalf. However, in some instances when a law requires us, we may share some private information with your insurance company.

• Get a list of those with whom we have shared your information. You can requestfrom us a list of the times we have share your health information for the past 6 years that will include who we shared your information with, what information was shared and for what purpose it was shared. PLEASE NOTE, we are unable to share your private information without a signed Release of Information from you.

• Get a copy of this privacy notice. You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a copy promptly.

• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• File a written complaint if you believe your privacy rights have been violated. We protect with your private health information with the highest level of confidentiality. However, if you believe your privacy rights have been violated, we would request that you contact us immediately. You also have the right to file a complaint with the US Department of Health and Human Services Office for Civil Rights by sending your complaint in writing to 200 Independence Avenue, S.W., Washington, DC. 20201 or by calling 877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

• Choose who we can share your information with. For certain health information, you can tell us your choices about what we share and this whom. If you have a clear preference for how we share your information, please talk to us and advise us what your instructions are.

• You have both the right and choice to instruct us to share information with your family, close friends, or others involved in your care. However, if you are unable to tell us your preference, for example if you are unconscious, we may share relevant information if we believe it is in your best interest. We may also share you information when needed to lessen a serious and imminent threat to health and safety.

• We do not share most psychotherapy and therapy visit notes or psychiatric informstion  without your specific permission in writing to do so.

Our Uses and Disclosures

We typically use or share your health information in the following ways:

• To treat you. We can use and share your information with other professionals who are treating you. For example, a doctor treating you for an injury or condition may ask another doctor about your overall health condition.

• To run our practice. We can use and share your health information for the general running of our practice, improve your care and to contact you when necessary. For example, we use health information about you to manage your treatment and services.

• Bill for your services. You may ask us to bill your insurance company for the services you receive which will include your health information. Other entities such as life insurance requests for records may entail sharing your health information but require your signed approval.

• Help with public health and safety issues. We are allowed, in some cases, to share your information in other ways for the purposes of public health and research. We have to meet many conditions in the law before such information for these purposes can be shared. For more information, please see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, prevent or reducing a serious threat to anyone’s health or safety are examples. We can also use or share your information for health research.

• Comply with the law. We will share information about you if state or federal laws require it, including the Department of Health and Human Services if it wants to see that we have complied with federal privacy law.

• Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.

• Work with a medical examiner or funeral director when an individual dies.

• Address workers’ compensation, law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law and other government requests such as military, national security and presidential protective services.

• Respond to lawsuits and legal actions that allows us to share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and  give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you also have the right to change your remind and revoke the authorization by informing us in writing.

• For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our web site.

I acknowledge that I have received a copy of the Notice of Privacy

Dr. Litzinger accepts most Blue Cross and Inited Hrealthcare Insurance Plans, however, it is up to the patient to check benefits prior to appointments.

Patients are responsible for co-payments and deductibles as well as any non-covered services.

•I hereby authorize Jeffrey Litzinger, MD to apply for benefits on my behalf for covered services with payments to be made to Jeffrey Litzinger MD. I certify that the information which I have provided with regard to my insurance is correct. I further authorize any holder of medical information about me to release any necessary information to my insurance company so that benefits may be obtained.

•I understand that I must provide a credit card to be held on file, and that payment (either the co-payment, if any, or the full payment for each appointment if no insurance is available) is due on the date of service. I may provide a check or credit card for professional fees due. If no payment is made prior to the end of the appointment, I authorize the provider to use the credit card/debit card on file portal for professional fees.

•Fees are as follows:

Initial Evaluation (45-60 minutes): $350

Follow- up medication management visits (15-45 minutes): $125-$200 (depending on the type of visit, and the time spent due)

No shows and cancellations:

•Please allow up to 24 hours for cancellations. The fee for a cancelled or missed appointment is $100. Cancellations within 24 hours will allow me to schedule another patient who is waiting for an appointment.

 

•I will not dispute charges (charge-back) for sessions I have received or for appointments I have missed according to the office policies, including missed appointments.

•I understand that I am responsible for the entire amount owed minus any payment made by my insurance company. I also understand by signing this form that if no payment has been made by me within 2 months of receiving a statement, my balance will go to collections if another alternative plan is not made 

By signing below, I am authorizing Jeffrey Litzinger, MD to charge for scheduled or missed appointments to the credit card on file, and I agree to the statements above.