Date of Birth
By accepting below, you consent to and authorize Tomer T. Levin MD or his associate, Lisa Lerner LCSW, to evaluate your medical condition and conduct any routine, non-invasive diagnostic and therapeutic procedures and treatments, which in their judgment are necessary for your care. You understand that you have a right to refuse any recommended treatment once it has been explained to you.
I accept and understand.
By accepting below you guarantee full payment for services rendered and to be rendered. If Assignment of Benefits is accepted, you are responsible for any bills not covered or allowed by governmental agencies or insurance carriers. You may present our billing statements to your insurance if you have out of network coverage. Billing statements will be delivered to your patient portal. Payment is expected at the time of the appointment. We require a credit card be kept on file for any outstanding charges. Balances over 30 days will incur a 1.5% monthly finance charge. Accounts with unpaid balances over 90 days past the date of service will transferred to a collection agency and incur a 40% finance charge.
By accepting below, you authorize release to billing services, governmental agencies, insurance carriers and/or others who are financially liable for your medical care, all information needed to substantiate payment for care. You give permission to their representatives to examine and make copies of all records relating to your treatment to the extent necessary to process claims.
By accepting below, you acknowledge receipt of the Notice of Privacy Practices and that you are aware that an electronic copy is available for review on your patient portal.
Notice of Privacy Practices link
I read, accept and understand Notice of Privacy Practices.
A. Collaboration: Coordination between healthcare providers is vital to your care. Prior to your first appointment, you should have had a physical exam and appropriate testing within the last 12 months. If possible, bring copies of tests to your first session. We will ask that you provide consent to obtain health records from your primary care provider or specialists.
B. Patient portal: This is the preferred method of communication because it is encrypted and HIPAA compliant. Dr. Levin’s and Lisa Lerner’s E-mail is encrypted but yours may not be secure. Electronic communication has potential risks to your privacy which you are aware of by consenting to this document.
C. Evaluation and Care Plan: The initial appointment is an evaluation. If you consent to the care plan and Dr. Levin or Lisa Lerner LCSW agree that you are a good fit, treatment will start. If our expertise does not match your needs, we will assist with appropriate referrals.
D. Cancellations and Punctuality: Appointments must be cancelled at least 24 hours in advance or you will be charged the full fee. (Note that weekends and holidays do not count as normal business hours. For example, if your appointment is on a Monday at 2:00 PM, we must be notified before 2:00 PM on the Friday prior to avoid being charged for the appointment). If you are sick, please enquire about converting your appointment to a tele-psychiatry visit.It is easy to do, even at the last minute. Appointment times are to be respected. If you are late, you will not be given extra time and will be billed at the scheduled rate. If you arrive too late to achieve any meaningful herapeutic work, at our discretion, your appointment will be rescheduled and you will be billed for a missed appointment.
E. Additional Services: Professional services between appointments including E-mails, telephone conversations, reports writing, coordination of care with family or other providers, or time spent performing any other services on your behalf will be prorated in 10-minute increment based on an hourly rate. Prescription refills between sessions are billed at a rate of $65.
F. Discharge from the Clinic: We reserve the right to terminate our relationship under the following conditions: if we believe our services are no longer beneficial or that another professional would serve you better; non-payment of fees; missing two appointments without appropriate notice; missing an appointment but not calling within 24-hours to explain what happened; not agreeing to or adhering to the treatment plan; you or a family member/friend breaks any law while on premises, are hostile to staff or disrupt the office; diverting or mis-using prescribed medication.
G. Feedback and Rights: Feedback is how we improve our care and will be addressed seriously and respectfully. It is your right to request a referral to another mental health practitioner or to end treatment at any time. You have the right to considerate, safe, ethical and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin. You have the right to ask questions about any aspects of therapy.
By accepting below, you are attesting that you have have read, understand, and agree to abide by the above practice policies.
Electronic Signature (draw it in box below)