PLEASE READ CAREFULLY BEFORE COMPLETING THE FORM

Thank you for trusting us with your healthcare needs; we look forward to meeting you and hope to exceed your expectations in every aspect of your behavioral treatment. Each employee at Pasadena Clinical Group is committed to enhancing the quality of your care and your overall experience. Filling out the form below will help us get acquainted with your medical history and help your therapist to target your plan.
Complete the form in each part to the best of your knowledge. Upon submission, our staff reviews it in 1 to 4 hours (during business hours). We may have to reschedule your appointment if anything is incorrect or missing.
If you are covered by two insurance plans, such as through your job and your spouse's job, or if you have Medi-Medi, you need to attach a copy of both insurance cards.
If you have a copay, you will need to pay it at the time of the visit, with no exceptions.
You will need a copy of your Driver's License (or any other government-issued ID), and a copy of your insurance card.
All attachments must be in PDF, JPG, or HEIC format. We cannot accept emails or other means of verification.

You can follow this check-list for your convenience:

1. Driver's License or a government-issued ID

2. Copy of all your insurance cards

3. Referral from your psychiatrist or primary care physician (if available)

4. Copy of any previous evaluations, including school-based assessments (if available)

Please set aside 6 to 8 minutes to complete the form.

Should you have any questions, please do not hesitate to contact our office for help at 626-354-6440, Monday through Friday, from 8 am to 7 pm.

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BILLING PARTY (person responsible for the copayments)

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Pasadena Clinical Group
Agreement & Consent to Recieve Psychological
and Psychiatric Services

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This document contains important information about our professional services and business policies. Please read it carefully and feel free to ask any questions you (from now on, known as the patient or the client) may have so that we can discuss them This form represents an agreement between us, and by signing it, you agree that you understand the nature and purpose of our services being provided to you and what our office policies are. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patients' rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them Based on your needs and current availability, you will have the option to work with a Psychologist, a Psychiatrist, a Social Worker, a Marriage and family therapist, a Professional Counselor, a Nurse practitioner, an Educational therapist, or a combination of them (from now on also referred as the clinician or the provider).

PSYCHOLOGICAL AND PSYCHIATRIC SERVICES

As a client obtaining psychological and/or psychiatric services, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. These rights and responsibilities are described in the following sections.

1. Psychotherapy. Psychotherapy can have benefits and risks; it is not like a visit to the medical doctor and calls for an active effort on your part. Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to offer significant benefits to people who go through it: it often leads to better relationships, greater personal awareness, and insight, increased skills for managing stress and resolutions to specific problems as well as significant reductions in feelings of distress. But there are no guarantees of what you will experience. Sometimes psychological services are provided primarily to prevent further deterioration of your mental or emotional status, which is considered maintenance treatment In order to be the most successful, you will have to work on things discussed during the session, both at the office (a. actively participating in the session, being on time, keeping your scheduled appointment) and outside (ex. reading at home). Psychotherapy also involves a significant commitment of time, energy, and money; if you have health insurance that covers your sessions, the costs are likely to be mitigated. Please ask your clinician about other treatments and their risks and benefits. If you have questions about our work, you should discuss them whenever they arise. If your doubts persist, we can help you obtain a second opinion. The first few sessions will involve an evaluation of your needs. You may receive services from any of our licensed clinicians or interns/associates.

2. Psychological and/or Neuropsychological testing. Psychological and'or Neuropsychological testing (including evaluation and assessments) consists of using a variety of techniques to establish information about your mental status, cognitive abilities, and neuropsychological functioning. Evaluations use a combination of intensive interviews, reviews of pertinent records, psychological test batteries, neuropsychological tests, and clinical observations in order to draw inferences regarding diagnosis, treatment plan, homicidal or suicidal ideation, or other issues (such as ADHD, ASD, thought disorder, ...). Under certain circumstances, we may recommend a psychiatric consultation, conjoint marital/couple, conjoint parent/child sessions, and/or group psychotherapy. You should evaluate this information and your opinions on whether you feel comfortable working with your clinician. Testings may be provided to you by licensed psychologists or interns/associates.

3. Group psychotherapy. Participating in group psychotherapy can result in numerous benefits, including improving interpersonal relationships and resolving the concerns that led you to seek (or to be referred for) group counseling. Working toward these benefits, however, requires active involvement, honesty, and openness on your part. Moreover, while group counseling is effective for many people and often leads to significant and lasting changes, some risks are involved. Many people report discomfort during group psychotherapy as they begin to look at areas in their life that aren't working or not working as well as they would like them to. Sometimes undesirable feelings can emerge as one considers unpleasant, difficult, or embarrassing subjects. The facilitator(s) or the group may suggest new and different ways of handling situations that may trigger upsets for you. Attempting to resolve tensions between yourself and others may lead to changes that were not originally intended. Moreover, a positive decision for one person can be viewed quite negatively by another. Change can happen quickly, but more often it can be slow and even frustrating. For some people, problems may get worse before they get better. It is also possible that group psychotherapy may not work for you. Even so, many people find that group counseling is worth the difficulty it may entail leading them to the intended results they seek. You may receive services from any of our licensed clinicians or interns/associates.

4. Medication. Psychiatric medications can be used in conjunction with psychotherapy to treat many conditions. Finding the best combination of medications and therapy that works for you is important. Your psychiatrist can provide an integrated approach as psychiatrists are trained to administer psychiatric medications and psychotherapy. However, in some situations, it may be appropriate to consider managing your psychiatric medications with your psychiatrist (or physician) and sharing the psychotherapy with an alternative clinician. Often called the 'split treatment' model, this should be discussed to determine if it is a viable option for you. We can help you find a clinician, whether at the Pasadena Clinical Group, APC, or in another setting; however, if you choose to obtain or continue your treatment at a different location, you will be responsible for any financial agreement between you and the facility/provider; we advise you to check in advance if the external facility or provider takes your insurance or agrees to your resources and means of payment. In situations that warrant the use of medications, you must understand the target symptoms and the likely outcomes. Additionally, since all medications have the potential for side effects, any prescribing provider at the Pasadena Clinical Group, APC will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which may include not using medications).

SESSIONS AND CANCELLATION POLICIES

Psychotherapy sessions vary in length and may go from 20 minutes up to 2 hours based on complexity; needs, and insurance coverage (if any). Psychological evaluations last several hours each session; group psychotherapy goes from 45 to 120 minutes based on the type. Medical evaluations range from 16 minutes up to 60 minutes or more. Once an appointment is scheduled, your payment is expected at the time we meet unless you provide 2 (two) full business days advance cancellation notice for scheduled individual psychotherapy sessions and five (5) full business days advance cancellation notice for group psychotherapy; psychological and/or neuropsychological evaluations, and medication services; no exceptions. Holidays and Saturdays, and Sundays are not considered business days. If you miss a session without canceling, as stated above, it is our policy to collect the amount of your payment unless we agree that you were unable to attend due to circumstances beyond your control; in general, these situations involve either a death in the family (first grade, for ex. father, mother, sister) or an unplanned medical visit (ex. Emergency Room). Proper paperwork is necessary to waive your fees for late cancellation or no-show. The fee for a missed appointment for a psychotherapy session (individual and couples) is 5225; for group and family psychotherapy is 5150. If possible, we will try to find another time to reschedule the appointment. However, this is based on the availability of your clinician and not a guarantee. The time scheduled for your appointment is assigned to you and you alone. In addition, you are responsible for coining to your session on time; if you are late, your appointment will still need to end on time. If you are using your insurance benefits, your insurance will cover only the time that you are present in session; late time shall be an out-of-pocket expense that you will incur; similarly; late cancellations andfor no-shows. Evaluations not canceled with a minimum of 5 (five) full business days advance notice incur a minimum charge of 5425. The only accepted methods of cancellation are telephone (626-354-6440) and fax (323401-8264); texts, emails, or other forms of communication are not accepted, with no exceptions. All copaysto-insurancedeductibles are charged 1 (one) business day in advance. Additionally, other professional services that require longer than 5 minutes are billed at 525 per 5-minute increment. This includes report writing, telephone conversations, and preparation of treatment summaries. Legal or court proceedings and any forensic work (even if by another party) are billed at 5800 per hour with a minimum of 2 (two) hours. Moreover, the hourly rate for any out-of-office proceedings (including depositions and court hearings) is based on the number of patient hours canceled to provide this service. These fees are subject to change over time and will be reviewed every year. We aatill also do our best to address this issue on an ongoing basis with the financially responsible party. Other services that you may need (such as correspondence and telephone meetings) are billed at the same rate as the associated service. In general, legal proceedings are not covered benefits by medical insurance companies. Please review this coverage with your health plan. All costs associated with your legal proceeding must be paid in advance, with no exceptions. If you have become involved in legal proceedings or if you anticipate becoming involved in a court case that requires the participation of your clinician, we recommend that we discuss this fully before you waive your rights to confidentiality. If your case requires the in-court appearance (whether in-person or via the Internet) of our clinician(s) you will be expected to pay for the professional time even if another party compels us to testify.

PAYMENTS AND COLLECTION OF PROFESSIONAL FEES

Any payment, such as insurance copayments, deductible, co-insurance, or out-of-pocket fees, must be made 24 hours before your scheduled session by credit card, debit card, check, or cash. If your copayment (and where it applies, your deductibles, coinsurance, or other costs) are not paid on time, a $35 late fee per session will be assessed. If your balance is above $25, you will need to pay that amount before scheduling a follow-up visit. If you pay by check, and your check is returned to our office, an additional fee of $35.00 to cover the bank fee and the administrative costs we incur (plus any late fee, if the case) will be added to the principal. Payment schedules for other professional services may be agreed upon when requested. In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or payment installment plan for out-of-pocket costs and/or deductibles andior copayments and/or coinsurance. If you pay by credit card, and your payment is declined, an additional fee of $35.00 to cover the administrative costs we incur (plus any late fee, if the case) will be added to the principal. All clients/patients are to have a valid credit card on file, which is saved to charge any balance that you incur. If your credit card is declined, you will need to update your card before scheduling a follow-up appointment.
If your account is overdue and other arrangements have not been made, we may use legal means to secure your payment. This may involve hiring a collection agency, an attorney, or going through the court system. If legal means are needed, basic personal information will be disclosed to secure your payment. If the balance is disputed, such as with a collection agency or an attorney, more information will need to be disclosed. We suggest you obtain legal advice to represent yourself with a collection agency to ensure you are aware of all your rights.

CONTACTING YOUR CLINICIAN

Your clinician may not be immediately available by telephone. Clinicians do not answer phone calls when clients patients are present or unavailable. If your clinician is unavailable, a monitored answering machine will be available for you to leave a voicemail. You may leave a message on your clinician's confidential voicemail if appropriate, and every effort will be made to return your call on the same day, except for weekends and holidays, but it may take a day or two for non-urgent matters; scheduling is not an urgent matter. If you are difficult to reach, please inform us of some times when you will be available. We do not offer emergency services. In the case of an emergency, please call 911 and/or proceed to the nearest emergency room (ER). If your clinician is unavailable for an extended time, a colleague will be covering for him/her In addition, contact via electronic communication is not used as a means of correspondence for therapeutic issues.

PROFESSIONAL RECORDS

The laws and standards of our profession require that we keep treatment records; they are maintained in a secure location. These are retained for seven years. You are entitled to receive a copy of your records or we can prepare a summary for you instead unless we believe that seeing them would be emotionally damaging or it could endanger a person's life, in which case we will discuss available options. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend you review them with your clinician so that he/she can discuss the contents with you. Clients will be charged an appropriate fee for any professional time spent responding to information requests.

CONFIDENTIALITY

In general, the client-clinician relationship is a professional relationship, and, therefore, private and confidential. All communications between client and clinician(s) are protected by law. Clinicians may only release your information to a requesting party with your written permission (should this be necessary or desired, we will have you sign a separate authorization form). But a few exceptions exist. For example, some situations legally require that we take action to protect others from harm, even if that requires us to violate your confidentiality. If your clinician believes that a child, elderly person, or disabled person is being abused, he/she must file a report with the appropriate state agency. If you are threatening serious bodily harm to another, we are to notify the potential victim, contact the police, and/or seek hospitalization for you. If you threaten to harm yourself, we may be obligated to seek hospitalization for you or to contact others who can help provide protection. In these situations, we make every effort to discuss these possibilities with you thoroughly. If you are a minor, the law may provide your parents the right to examine your records. We typically either request that they relinquish such access or provide them only with general information about our work together. We may occasionally find it helpful to consult other professionals for help, in which case we will avoid revealing your identity. We may be using specific electronic devices to process your payments (for ex. credit card machines, clearing house), store sessions records, or communicate with you, including cordless telephones, cellular phones, fax, email, or other devices that use the Internet as means to reach the other party: we cannot guarantee the security of these communication methods so signing this document acknowledges that you understand and accept the inherent privacy risks involved. If you are using your insurance benefits, we must disclose some information with your insurance to process the claim(s). You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law ensures the confidentiality of all electronic transmission of information about you. If you elect to communicate with your clinician by email, text, or other electronic means, please be aware that these methods are not completely confidential. Basic or complete information (such as IP Address, destination phone number, time, date, and place of origin of electronic communication) about emails, faxes, and text messages may be retained in the logs of your chart and the logs of the utility's company servicing your clinician (ex. Verizon). While under normal circumstances, no one looks at these logs, they are, in theory, available to be read by the utility company's system administrator(s) used by our office or the clinician. The communication we receive from you, and any responses that we send to you, may be printed out and/or saved and kept in your treatment record depending on the nature and purpose of the communication and whether we decide to keep it or not. As indicated earlier, there are some exceptions to confidentiality:

1. If we believe that a client/patient is threatening serious bodily harm to another, we are to take protective actions. These actions may include notifying the potential victim, contacting the police, and seeking hospitalization for the client. If the client threatens to harm himself'herself, we may be obligated to seek hospitalization for him/her or contact family members or others who can help provide protection. We will take any threats seriously, whether we are informed by you or someone you know. Therefore, please use discretion when providing our contact information to a third party.

2. You should be aware that when psychological services are sought by third parties such as employers, lawyers, or the courts, disclosure of some information is by law. You should also be aware that disclosure of requested information to third parties, when mandated by law, could potentially harm your life. These situations have rarely occurred in our practice. We will make every effort to discuss it with you before taking any action unless we believe that notifying you may put you or your health in jeopardy. We may occasionally find it helpful to consult other professionals about a case. During a consultation, we make every effort to avoid revealing identifying information. The consultation is legally bound to keep the information confidential. If you don't object, we will not tell you about these consultations unless we feel they are important to our work together.

3. If your clinician is unexpectedly unable to make your appointment or contact you personally, you may be contacted by a colleague. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential situations, we must discuss any questions or concerns you may have any time they arise. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be necessary because the laws governing confidentiality are quite complex, and our clinicians are not attorneys.

4. In most legal proceedings, you have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order the direct testimony of your clinician if he/she determines that the issues demand it. In addition, there are some situations in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a client's treatment. For example, if we believe that a child, elderly person or disabled person is being abused, our clinician must file a report with the appropriate state agency.

You can fmd further information about confidentiality and other information about your privacy rights in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document, and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work.

MINORS

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. To strengthen the trust in your clinician, we may request an agreement from parents that they give up access to your records. If they agree, your clinician will provide them with general information about your work together unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of any concerns. We will also provide them with a summary of your treatment when treatment is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle objections you may have with what we are prepared to discuss.

DIAGNOSIS

If a third party, such as an insurance company, is paying for part of your bill, we must give that third party a diagnosis to be paid. Diagnoses are technical terms describing the nature of your problems and whether they are short-term or long-term problems. If we do use a diagnosis, we will discuss it with you. All diagnoses come from a book titled the DSM-V-TR, published by the American Psychiatric Association. Furthermore, if you are using your insurance benefits, we may be to disclose your medical records to your insurance or a third party hired by your insurance for risk assessment and/or other provisions authorized by the law. By signing this consent form, you allowed us to disclose this information per the law.

TERMINATION

Your participation in any psychological services is voluntary, and you have the right to withdraw from treatment without adversity at any time. We recommend that when termination is considered, you discuss this with your clinician so that we can create a plan for termination to minimize any possible adverse effects. If you don't show up for two consecutive scheduled appointments or three scheduled appointments in six months, your treatment will be considered canceled and terminated, and you will be financially responsible for the fees for the missed sessions. You may receive a letter acknowledging the termination and a closing bill for any unpaid balance.

OTHER RIGHTS

You have the right to ask questions about anything that happens in therapy. Your clinician is always willing to discuss how and why he/she has decided to do what he/she is doing and to look at alternatives that might work better. You can ask him/her to try something that you think will be helpful. You can ask about his/her training for working with your concerns and request that he/she refer you to someone else if you decide heishe is not the right clinician. You are free to leave at any time.

INDIVIDUAL RIGHTS GRANTED BY THE HIPAA PRIVACY RULE

In general, you have the right to view your PHI in our possession or obtain copies of it Under certain circumstances, such as if we fear the information may harm you, we may deny your request. In such a situation, we will provide the reasons for the denial and release your PHI to another health care clinician if you wish. We will charge you no more than $.25 per page for copies of your PHI. You have the right to ask that we limit how we use and disclose your Pill. While we will consider your request, we are not legally bound to agree. If we agree to your request, we will put those limits in writing and abide by them except in emergencies. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, e.g., those for treatment, payment, or health care operations. The list will consist of the date of the disclosure, to whom PHI was disclosed (including their address if known), a description of the information disclosed, and the reason for the disclosure. If you believe that we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint by submitting a written complaint to us. If you prefer, you may file your written complaint with the Secretary of the U.S. Department of Health and Human Services (Secretary) at 200 Independence Avenue S.W., Washington, D.C., 20201. However, any complaint you file must be received by us or filed with the Secretary within 180 days when you learned that the omission occurred.

TELEHEALTH/TELEMEDICINE

Telehealth/Telemedicine is the distribution of healthcare-related services, information and treatment via electronic and telecommunication technologies. It allows patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. By participating in your treatment at the Pasadena Clinicla Gorup you consent to engage in telemedicine as part of your treatment. Telehealth/Telemedicine senices may include interactive audio, video, or data communications including your mental health information, both orally and visually, to other health care practitioners as part of your treatment or care coordination as provisioned by the law.

TECHNOLOGY

To participate in Telehealth/Telemedicine you may need to download an application and/or software to use this service. You also need to have a broadband Internet connection or a smartphone device with a good cellular connection at home or at the location deemed appropriate for services. In case of technology failure, you can contact Pasadena Clinical Group, APC via phone to coordinate alternative methods of treatment. It is your responsability to ensure that your deseice(s) is capable or suitable for Telehealth/Telemedicine. Pasadena Clinical Group, APC is not responsible for any cost you incur for setting up your end of the communication, such as the intemet connection/plan, the phone line, the computer and/or timilar

CONVERAGE AND INSURANCE BENEFITS

Generally insurance cover Telehealth/Telemedicine appointments, however you are responsible for contacting your insurance company, if applicable, to determine what your coverage and any out-of-pocket costs is. You authorize insurance benefits to be paid directly to Pasadena Clinical Group, APC and that Pasadena Clinical Group, APC may release any information to my insurance provider for processing my claims. If you choose not to use your insurance benefits, or if your insurance does not cover any or all services at Pasadena Clinical Group, APC or you don't have a health insurance, the fees associated with telemedicine appointments are indicated below, and agree to pay them one business day in advance. You can cancel! Telehealth/Telemedicine appointments in accordance with the Pasadena Clinical Group, APC cancellation policy as documented in the office policy. Amounts paid for telemedicine/telehealth services at Pasadena Clinical Group, APC including late cancellations, are non-refundable.

FEES FOR TELEMEDICINE/TELEHEALTH SERVICES

Initial Consultation (intake): $250/30-45 minutes (or, if we take your insurance, the contracted rate).
Follow up visit for therapy, psychotehrapy, or counseling: $125/45-60 minutes (or, if we take your insurance, the contracted rate).
Psychological Testing: $325/60-75 minutes (or, if we take your insurance, the contracted rate).
Neuropsychological Testing: $425/60-75 minutes (or, if we take your insurance, the contracted rate).
Verify with your insurance coverage for Telemedicine/Telehealth, including but not limited to phone consulation and video sessions.

SCHEDULING

Scheduling is conducted through Pasadena Clinical Group, APC and is based on the clinician's normal clinic hours. Telemedicineftelehealth appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Pasadena Clinical Group, APC does not provide emergency services. Crisis or mental health emergencies should be directed to the local county crisis line, or by dialing 911, or by going to the nearest ER.

VIDEO/AUDIO RECORDING

As a general practice Pasadena Clinical Group, APC does not record Telemedicineitelehealth sessions without prior permission. During the session, copyright materials may be used to further explain an individual's difficulties. Sessions cannot be recorded without prior consent, nor allow any third party to do so. You are responsible for any cost incurred by Pasadena Clinical Group, APC if legal action are , as a consequence of your wrongdoing.

SESSION CONFIDENTIALITY

The laws that protect the confidentiality of your medical information apply also to telemedicinettelehealth. As such the information disclosed during the course of the treatment are generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where you make your mental or emotional state an issue in a legal proceeding. Pasadena Clinical Group, APC's Telemedicine/telehealth service is HIPAA compliant to protect privacy and confidentiality, as explained in this Informed Consent. During a declaration of a State of Emergency rules may change, and some restrictions lifted to allow patients/clients to access health care services for continuity of care: please inquire to your clinicians if/when these rules change and how they may impact your confidentiality. Pasadena Clinical Group, APC will do everything possible to ensure that medical records are always kept safe.
To protect confidentiality and facilitate the security of medical information, as much as possible, you agree to follow these recommendations:

1. Participate from a private location where you cannot be heard by others

2. Use a private phone line;

3. Use a password protected technology to interact with the clinician;

4. Log out or hang up once the session is complete.

RISKS/BENEFITS

There are risks/benefits with respects to telemedicine and telehealth, specifically:

1. The transmission of medical information could be disrupted or distorted by technical failures. Telemedicine and telehealth-based services may not be as complete as face-to-face services. If your clinician believes that you may be better served by another form of treatment (e.g. face-to-face services) you wil receive referrals;

2. Benefits from telemedicine telehealth services cannot be guaranteed or assured;

3. Pasadena Clinical Group, APC may not provide telemedicine/telehealth services to you if you are located outside of the State of California;

4. Despite every effort, security protocols could fail, causing a breach of privacy of personal and/or medical information; if that happens, you agree not to hold Pasadena Clinical Group, APC responsible for any consequence or damage caused by a breach of confidentiality or privacy.

5. you have the right to withhold or withdraw your consent to the use of telemedicine/telehealth in the course of your care at any time, without affecting your right to future care or treatment, however if your current clinician/provider does not offer a face-to-face treatment he/she will refer you to other providers who may be able to assist you. It is your responsibility to verify directly with the referrals given whether they provide telemedicine/telehealth and if they take your insurance.

ACKNOWLEDGING SIGNATURES

By signing this document below, you indicate that you have read and that you understand this Agreement and Consent to Receive Psychological and/or Psychiatric Services, which contains information on psychological and psychiatric services, sessions, professional fees, cancellation and no-show policies, billing and payments, insurance reimbursement, how to contact your clinician(s), access to professional records, confidentiality, and practice status, and you agree to abide by its terms during our professional relationship. Furthermore, by signing this document, you indicate that you have received and understand the Notice of Privacy Practices and agree to their terms. You understand and agree to comply with them. You also understand that Federal regulations (HIPAA) allow us to disclose your PHI under certain circumstances, as described above. You consent to the use or disclosure of your PHI as specified. You understand that this consent is voluntary, and you may refuse to sign it now and/or revoke it later.

Pasadena Clinical Group, APC
Notice of Privacy Practice and PHI Disclosue

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We are committed to protecting your privacy and confidentiality to the full extent of the law This notice describes how your psychological and medical information may be used and disclosed and how you can access this information This notice conforms to the Federal Health Insurance Portability and Accountability Act (HIPAA), effective April 14, 2003. It also conforms to the health care privacy laws of California. Please read it carefully.

PHI (Patient Health Information)

The services you are receiving here concern your psychological and/or psychiatric status, a most private and intimate component of your life. Therefore, protecting your privacy is of utmost importance. The following paragraphs explain how, when and why we may use and/or disclose your records, known under the HIPAA legislation as "Protected Health Information" (PHI). Your PHI consists of individually identifiable information about your past, present, or future health (or conditions and the provision of) and payment for health care you receive. We may also receive your PHI from other sources, i.e. other health care providers, attorneys, etc. You and your PHI receive certain protections under the law. Except in specified circumstances, we will not release your PHI to anyone. When disclosure is necessary under the law, we will only use and or disclose the minimum amount of your PHI necessary to accomplish the purpose of the use and/or disclosure.

USE AND DISCLOSURE OF PHI

If you are receiving any psychological and/or psychiatric service, your PHI is typically limited to basic billing information and progress notes placed in a file. Clinical notes taken after sessions are known as Psychotherapy Notes and are not part of your PHI. Except in emergencies, such as child or elderly abuse, homicidal or suicidal intention (and other law provisions), your PHI will only be released with your specific Authorization. In accordance with the HIPAA act and its Privacy Rule (Rule), your PHI may be used and disclosed for a variety of reasons. Again, however, every effort is made to prevent its dissemination. For most other uses and/or disclosures of your PHI, you will be asked to grant your permission via a signed Authorization which is a separate form. However, the Rule allows for certain specified uses and/or disclosures of your PHI. These consist of the following:

1. Uses and Disclosures Not Requiring Your Authorization nor your Consent ( The Rule provides that we may use and/or disclose your PHI without your Authorization in the following circumstances):

   1. Uses and/or disclosures related to your treatment (1), the payment for services you receive (P), or for health care operations (0):

      1. For treatment (1): we may use and/or disclose your PHI to psychologists, psychiatrists, physicians, nurses, and other health care personnel involved in providing health care services to you.

      2. For payment (P): we may use and/or disclose your PHI for billing and collection activities.

      3. Health care operations (0): Health Care Operations are activities that relate to the performance and operation of our practice. We may use or disclose, as needed, your protected health information in support of business activities. For example, when we review an administrative assistant's performance, we may need to review what that employee has documented in your record.

   2. When by law: we may use and/or disclose your PHI when existing law requires that we report information including but not limited to each of the following areas:

      1. Reporting abuse, neglect or domestic violence: we may use and/or disclose your PHI in cases of suspected abuse, neglect, or domestic violence including reporting the information to social service agencies.

      2. Judicial and administrative proceedings: we may use and/or disclose your PHI in response to an order of a court or administrative tribunal, a warrant, subpoena, discovery request, or other lawful process.

      3. To avert a serious threat to health or safety: we may use and/or disclose your PHI in order to avert a serious threat to health or safety. For example, if we believed you were at imminent risk of harming a person or property, or of hurting yourself, we may disclose your PHI to prevent such an act from occurring. Your information may not be privileged if you are seeking therapy to avoid jail or commit a crime.

      4. Health Oversight: if a complaint is filed against us, your provider or any employee of this company with the California Board of Psychology, the Medical Board: the Board has the authority to subpoena confidential mental health information from us relevant to that complaint.

      5. Worker's Compensation: we may disclose PHI as authorized by the law, and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, that provide benefits for work-related injuries or illness without regard to fault.

2. Uses and/or disclosures requiring your Authorization

   1. Generally, our use and/or disclosure of your PHI for any purpose that falls outside of the definitions of treatment, payment, and health care operations identified above will require your signed Authorization. If you grant your permission for such use and/or disclosure of your PHI, you retain the right to revoke your Authorization at any time except to the extent that disclosure might already have been made

PATIENT'S RIGHTS AND PSYCHOLOGIST'S DUTIES

The HIPAA Privacy Rule grants you the following individual rights:

1. Right to Request Restrictions — You have the right to request restrictions on certain uses/disclosures of PHI. However, we are not to agree to the request

2. In general, you have the right to view your PHI in our possession or obtain copies of it You must request it in writing. You will receive a response from us within five days if you decide to access your records, fifteen days if you want a copy of your records and, depending on its length, between ten and thirty days if you request a summary of your records of our receiving your written request. Under certain circumstances, such as if we fear the information may harm you, we may deny your request. If your request is denied, you will be given the reasons for the denial in writing. We will also explain your right to have our denial reviewed. We will charge you no more than $.25 per page if you ask for copies of your PHI. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree in advance to it and the cost.

3. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergencies. You do not have the right to limit the uses and disclosures that we are legally or permitted to make.

4. Your right is to ask that your PHI be sent to you at an alternate address or by an alternate method, e.g., digital format We are obliged to agree to your request providing that we can give you the PHI in the format you requested without undue inconvenience.

5. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, e.g., those for treatment, payment, or health care operations. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, to whom PHI was disclosed (including their address if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one request in the same year, in which case we will charge you a reasonable fee for each additional request.

6. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request We may deny your request in writing if we fad that the PHI is: (a) correct and/or complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than our clinicians. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made and advise all others who need to know about the change(s) to your PHI.

7. You have the right to get this notice by email if you choose to. You have the right to request a paper copy of it as well.

8. If you believe that we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint by submitting a written complaint to us. Your written complaint must describe the acts and/or omissions you believe to violate the Rule or the provisions outlined in this Privacy Practices section. If you prefer, you may file your written complaint with the Secretary of the U.S. Department of Health and Human Services (Secretary) at 200 Independence Avenue S.W., Washington, D.C., 20201. However, any complaint you file must be received by us, or filed with the Secretary within 180 days of when you knew, or should have known, that the act or omission occurred. We will take no retaliatory action against you if you make such complaints.

ACKNOWLEDGING SIGNATURES

By signing this document below, you indicate that you have received, read, and understand this Notice of Privacy Policy and agree to comply with it. You also understand that Federal regulations (HIPAA) allow us to disclose your PHI under certain circumstances, as described above. You consent to the use or disclosure of your PHI as specified. You understand that this consent is voluntary, and you may refuse to sign it now and/or revoke it later.

Pasadena Clinical Group, APC
Mediation and Arbitration Agreement Explaination for Patients

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Introduction

Arbitration is an alternative dispute resolution procedure endorsed by groups such as the California Medical Association and is noted to be a favored method of resolving disputes by the United States Supreme Court. If you are unfamiliar with arbitration in general, the information included here provides some of the basic principles of arbitration.

What is arbitration?

Arbitration is an alternative way of resolving disputes. Instead of taking your disagreement through the long and expensive process of court litigation, you and the group practice/doctor agree in advance to submit any disputes to an arbitrator for his or her determination. The arbitrator is selected from among the numerous retired judges available and qualified to serve on these matters and is mutually agreed upon by you and the doctor. After the arbitration hearing, which is usually less formal than a court proceeding, the arbitrator makes the decision ("award"). Although the procedures are different, the same laws and measures of damages in court proceedings also apply in arbitration.

Does arbitration prevent you from making a claim?

No. By selecting arbitration as the means to resolve a disagreement, you are essentially moving the claim to a different forum (i.e., from a jury to an arbitrator) to hear and ultimately decide your claim.

Does it prevent you from obtaining a financial award?

No. Arbitration does not restrict or prevent you from obtaining a financial award in any manner. If the arbitrator accepts and agrees with your claim, he will determine a damage award. The United States Supreme Court has, in fact, previously held that arbitration is strongly favored as an expeditious and economical alternative to the court system.

May an attorney of my choice represent me?

Yes. Any party to the arbitration may be represented by an attorney of his or her choice at his or her own expense. The arbitrator will hear the facts and decide whether or not lawyers represent the parties.

Who is bound by this agreement?

If you choose to sign the arbitration agreement, you will agree to bind yourself and anyone who could bring suit in connection with treatment or services provided to you by the doctor. If you sign on behalf of a family member or another person for whom you are responsible, you will bind that person and anyone who could sue in connection with treatment or services provided to that person by the doctor. Likewise, the doctor or anyone suing on behalf of the doctor is bound.

What does arbitration cost?

In general, arbitration is less expensive than court actions. The arbitrator's fees are ordinarily shared equally by the parties. Those fees will depend upon the complexity and length of the case.

Pasadena Clinical Group, APC
Mediation and Arbitration Agreement Explaination for Patients

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Article 1: Agreement to Arbitrate: It is understood that any dispute for malpractice, in regards to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract agree that by entering into it, they are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the provider, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean the mother and the mother's expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the provider, and the provider's partners, associates, association, corporation or partnership, and the employees, agents, and estates of any must be arbitrated, including without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing any court by the provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by US mail with pre-paid postage to all parties describing the claim against the clinician(s), the amount of damage sought, and the names and addresses, and telephone numbers of the patient(s) and if applicable of his/her attorney. Each party shall select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate the issues of liability and damages separately upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by mitten notice delivered to Pasadena Clinical Group, APC by Us Mail with pre-paid postage within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California and federal law.

Article 7: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should sign below:

Patient's or Patient Representative Signature *

Effective as of the date of first medical services.

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ACKNOWLEDGING SIGNATURES

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT

Pasadena Clinical Group, APC
Office Policies

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At the Pasadena Clinical Group, APC we strive to provide the best Mental Health Care possible. Our goal is to help our patients and clients eliminate their pain, distress, and emotional problems while helping them use their distinct talents and judgment to achieve their best health, happiness, and success. We will do our very best and expect our patients to as well. The following policies have been established to ensure the best patient care possible. It is therefore important that you agree with our office policies:

• I agree to be on time for all appointments, be prepared, and ready to go

• I agree that an intake session (in-person or online) is necessary to assess my condition(s) and to conduct a psychological and/or psychiatric evaluation.

• I am responsible for providing up-to-doe insurance information and agree to pay for all services not covered by my insurance. I also agree to update the Pasadena Clinical Group, APC, if there is any change to my insurance coverage.

• I acknowledge my responsibility to know and understand the terms and conditions of my health Insurance coverage. I understand that the information my clinician receives from my insurance company is never a guarantee of benefits and is used only as a guideline.

• I agree to pay $35.00 for returned checks or declined credit card transactions. Any balance must be paid before scheduling further appointments. I agree to pay any collection cost if a balance is referred for collection.

• I understand that my copay/co-insurance/deductibles are charged I agree to pay any copayment, coinsurance, deductibles (if any), non-covered services and services rendered beyond the maximum allowed by my policy/health plan one business day before my appointment. I understand that the office may charge me a $35 late fee if my balance is not paid on time.

• I agree to notify my clinician:

  • 1(one) full business day in advance, excluding weekends and holidays, if I need to reschedule or cancel my therapy appointment;
  • 3 (three) business days in advance, excluding weekends and holidays, if I need to reschedule or cancel my testing session;
  • 3 (three) business days in advance, excluding weekends and holidays, if I need to reschedule or cancel my medication appointment.

  If I reschedule, cancel, or miss an appointment outside the agreed timeframe, I agree to pay the session's fees: $225 for a therapy session, $300 for a psychiatric appointment, and $425 for a testing session.

• I agree to have a valid credit card on file and authorize the Pasadena Clinical Group, APC, to charge my credit card for co-payments, co-insurance, deductible, and any balance I incur. It is my responsibility to verify with my health plan if I have any copayment, co-insurance, and/or deductibles. I understand my credit card will be saved on file.
• I understand that the Pasadena Clinical Group, APC does not provide emergency services and that I must call the 911 or go to the nearest Emergency Room (ER) if there is an emergency or a life-threatening situation.
• I agree to pay by a personal check any amount greater than $30 if asked to do so by Pasadena Clinical Group, APC.
• I authorize the Pasadena Clinical Group, APC, to contact me for follow-up appointments, treatment operations, and billing services by phone, email, and/or text messages. I understand that my phone carrier may charge fees to receive phone calls, text messages, or use the internet to check my emails, and I am responsible for verifying these charges with my phone provider. The Pasadena Clinical Group, APC is not responsible nor liable for any cost debited to me by my phone carrier.
• I authorize Pasadena Clinical Group, ACP to release medical information to my insurance company for treatment, operation, billing and payment services as explained in the Informed Consent and the Notice of Privacy Practice.

ACKNOWLEDGING SIGNATURES

By signing this document below, you indicate that you have read that you agree to the office policies

ASSESSMENT CHART

This is a confidential document. It is intended to help you discuss your well-being openly with your doctor. Please answer each question to the best of your knowledge.

Please provide the date, type of treatment, and length

(Ex: 1993 - Therapy - 2 months - Not beneficial)

Check mark any of these symptoms that have occured during the past 6 months

Check mark any of these symptoms that have occured during the past 12 months