Patient Agreements and Authorizations

CONSENT FOR TREATMENT.

I hereby consent to the treatment provided by Dr. Marla Kushner and its employees or designees. I authorize the mental and physical health care services deemed necessary or advisable by my caregivers to address my needs.

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION.

I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare opeartions of Dr. Marla Kushner. I authorize Dr. Marla Kushner to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Dr. Marla Kushner may release objective clinical information related to my diagnosis and treatment, which may be requested, by my insurance company or its designated agent.

ASSIGNMENT OF INSURANCE BENEFITS/PAYMENT GUARANTEE/COLLECTION FEE.

I authorize payment to be made directly to Dr. Marla Kushner for insurance benefits payable to me. I understand that I am financially responsible to Dr. Marla Kushner for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the costs of collection including reasonable attorney fees.

I acknowledge having received Dr. Marla Kushner's. "Notice of Privacy Practices". My rights including the right to see a copy of my record, to limit disclosure of my health information, and to request an amendment to my record, is explained in the Policy. I undestand that I may revoke in writing my consent for release of my health care information, except to the extent Dr. Marla Kushner has already made disclosures with my prior consent.

Name:

Patient or Authorized Person Signature

Relationship

Date:

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Witness Signature:

Date:

Your information will be encrypted.