Notice of privacy practices

In order to allow us to provide you with services, we ask that you carefully read the following statements:

CONSENT FOR CARE AND SERVICES

I understand that LICC's professional and administrative staff will make the necessary judgments about the services I will receive. The professionals who provide these services may include certified psychologists, social workers, psychiatrist, as well as other professionals in internship status, advanced fellowship status, or other post-professional training and intern positions.

I give my consent to LICC, as an accredited and licensed mental health facility, to provide me with the needed clinical services.

FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

Patient's Responsibility to LICC. I understand that I am responsible for my co-payments. Furthermore, I understand that co-payments must be paid on the day of my appointment. Please read your insurance policy carefully and understand your benefit coverage. Bring your insurance card to the clinic, so we can make a copy for your records. I understand that it is my responsibility to notify LICC of any changes in my coverage. Failure to notify LICC of changes could result in services not being covered. I understand that I will be billed for any uncovered services. 

Assignment of Benefits. I assign and authorize insurance payments to LICC. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles except where my liability is limited by contract or State or Federal law. A duplicate or faxed copy of this document is considered the same as the original document. 

AUTHORIZATION OF RELEASE OF INFORMATION TO INSURANCE CARRIERS

I authorize LICC to verify my insurance benefits and obtain all pertinent financial information concerning my coverage and payments under my policy. Furthermore, I authorize LICC to release confidential medical/psychiatric/substance use information requested by my insurance carrier to facilitate reimbursement of my medical fees.

NOTICE OF PRIVACY PRACTICES VERIFICATION

I verify that I was given a Notice of Privacy Practices by LICC. LICC is required by the Health and Insurance Portability and Accountability Act of 1996 (HIPAA) to distribute this notice. This notice describes how I can get access to my protected health information, if I so desire.

I understand that if I have any questions about the Privacy Notice, I can contact the Privacy Officer at Long Island Consultation Center at (718) 896-3400.