Thank you for your interest in Zohar Health!

Please call us at (301) 250-0404 for the access code for this form. 

NEW CLIENT INTAKE FORM

INSURANCE AND BILLING

GENERAL CONSENT FOR TREATMENT

General consent form explains telemedicine and other major administrative policies.

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.  The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, medical images, Live two-way audio and video, output data from medical devices and sound/video files. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits are Improved access to medical care by enabling a patient to initiate a visit to consult with a healthcare practitioner from a remote site, more efficient medical evaluation and management and obtaining expertise of a remote specialist.

Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine.  These risks include, but may not be limited to; In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider  and consultant(s).Delays in medical evaluation and treatment due to deficiencies or failures of the equipment, failure of  security protocols causing a breach of privacy of personal medical information,  lack of access to complete medical records resulting  in adverse drug interactions or allergic reactions, or other judgment errors.

 
By signing this form, I agree to the following:

1.  I understand that the laws (Health Insurance Portability & Accountability Act of 1996 HIPAA)  that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.

2.  I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment and I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

3.  I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.  I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured and telemedical examinations or care may not be as complete as a face to face examination or care.

4.  I understand that I cannot record any of the interactions I have with my provider during the session via audio or video methods, and will be held liable for privacy violations if I do and interaction will be private, and at any cost should not involve social media.

5.  I understand that when I use electronic communication (fax, text messages, phone or email) there can be unintended disclosure to third parties, and I hold Zohar Health  not liable for the same. 

Administrative, Financial, Communication, Third Parties and Treatment related 

1.  I give Zohar Health consent to check my prescription history from I-Stop (NY), Crisp (MD) and PDMP (DC) programs.

2.  I understand I have to provide Zohar Health copies of EKG, physical and recent laboratory reports every year and I have to be under the care of  a primary care provider.

3.  I understand if Zohar Health Provider(s) assigns me for face to face assessment one or two times in a year, it will be based on clinical judgment which includes, but is not limited to being on antipsychotic, stimulants and/or controlled substances, existence of other medical conditions and age.  I will make necessary arrangements to see provider(s) at Lynbrook office in New York or Rockville office in Maryland depending on my domicile. 

Collaboration and Emergency Contact

Zohar Health is allowed to contact the person who is my designated emergency contact in case of perceived or reported life threatening medical or psychiatric emergencies. Zohar health is allowed to share and receive information from my medical providers and therapist(s) verbally and electronically for treatment purpose.

Communication

I agree to receive text messages and secure emails from Zohar Health and the other third party agencies (under HIPAA compliance) with whom Zohar Health contract as business associates. I will be provided a secure email to contact Zohar Health  and  I am responsible for the protection of my username and password and if I chose non secure platforms to contact Zohar health, it will be at my risk and responsibility. 

Payments

I acknowledge that I am responsible for co-payment, or deductible or co insurance for health services provided to me towards Zohar Health I am aware that I am responsible for communicating any changes in my insurance and failure to do so can result in denial of my claims and I will be responsible for the full payment of the visit. I understand that Zohar Health  will initiate collection process in the event of nonpayment. I give consent to Zohar Maxcare Inc  to charge my credit card attached to my file.  If the card is declined my visit can be denied and I attest that I will pay the required co-payment and/or deductible to Zohar Maxcare Inc  via a secure link provided to me. 

Appointments and Cancellations

I understand that I have to provide a 24-hour notice for cancellation, and I will be charged a $75 cancellation fee if the cancellation is after the 24-hour period. 

Pharmacy

Some medications will require prior authorizations (PA), which may take up to 72-hours and could result in a denial which can affect my care. I allow Covermymeds, a third party provider with BAA to request for PA for me.

Documents

Zohar health requires two weeks’ notice to release /prepare documents and need.

Any additional requests for services such as assistance with disability application, letters for court, clearance, or attorney consultations will be prorated based on the full hourly clinical rate (currently $350). These services are not covered by insurance and will be considered out of pocket expenses and must be paid in advance of the service. If representation at the court is required, Zohar Health has a policy which will be available on request.

Termination of Care

My care can be terminated if there is a treatment and policy nonadherence, noncompliance with follow up, absence for three months, two consecutive cancellations without notice and two cancellations in a 4-month period and If I obtain treatment from other providers for the same diagnosis. Abusive or threatening behavior, display of firearms or weapons are reasons for immediate discharge.  Zohar Health will try to contact me if I miss my appointment via text and or a phone call once in the first month and in the second month via secure email with a plan to discharge me. I will receive a final discharge notice only via secure email after Zohar health settles financial transactions with the insurance company. 

Reviews

I understand that writing a review on the internet or social media regarding Zohar Health can expose my identity, and I am solely responsible for the ramifications, if any. I also understand that Zohar Health has the right to defend their reputation, and can initiate legal proceedings against me for tarnishing messages on the internet. I will try to resolve any issues related to treatment and/or administrative protocol with Zohar Health, first.  

I have read and understand the information provided above regarding telemedicine and in person visits and have discussed it with my provider or designees and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine/ telepsychiatry/ in-person visits for my psychiatry and mental health care to Zohar Health Psychiatry and Mental Health (NY, MD, DC).

I here by declare that all the information furnished by me is true to the best of my knowledge, and that I seek this care voluntarily.

INFORMED CONSENT FOR TREATMENT

I understand and expect that my provider will explain the nature of my mental illness, and together we will decide a course of treatment. It can be Psychotherapy alone, Psychotherapy in conjunction with pharmacotherapy or pharmacotherapy alone. I understand I am consenting to those services that the provider(s) at Zohar Health is qualified to provide within the scope of the providers license, certification and training. I understand that my consent may be withdrawn at any time, and I will need to notify my provider. I understand that I have to be under the care of a primary care practitioner while working with Zohar Health. I have to disclose the use of other medications, herbs, over the counter drugs, pain medications, recreational substances and other substances to my provider which can exacerbate or mask my symptoms, to avoid drug interactions and to prevent complications. 

If I am prescribed medications, I will be informed the reasons for taking the medications ,the risks and benefits of treatment, the likelihood of improving without medications, and other possible alternative treatments.

If I am prescribed medications, the most common side effects of the medications will be explained during sessions. If I have any further questions, I can always ask my provider. If any unexpected side effects should occur, I have to notify my provider immediately.  In case I cannot reach my provider, I must seek medical attention by going to an urgent care center or ER. I have an option to ask for handouts regarding medication management. I can access the NIMH (National Institute of Mental Health) website to learn more about my illness or medication.

If I am prescribed medication, my consent is voluntary.

If I am prescribed medication, I understand that there may be risks & benefits associated with pharmacotherapy. I have an option to do pharmacogenomic testing via Zohar Health.  I understand there are inherent risks involved in taking psychotropic medication, which include but not limited to metabolic syndrome, tardive dyskinesia and or Steven Johnson Syndrome.

If I am prescribed medications, I understand that mixing medications with substances of abuse can be lethal.  I understand that operating machinery or driving while taking medications can be hazardous and consumption of Grapefruit juice can affect efficacy of psychotropics.

If I am prescribed medications, I understand that more than one prescriber cannot treat me concurrently for the same condition with medication.

If I am prescribed medications, I understand that discontinuation of the prescribed medication(s) without consulting my provider, may result in worsening of my condition.  I am advised that my provider will follow FDA guidelines in prescribing, and any off-label use will be discussed separately (but does not require a separate consent). Titrating, tapering, presence of side effects or request for a 90 day supply medication will require a visit.

I understand that I have to provide Zohar Health copies of my recent EKG, Physical and laboratory reports, every year.  I understand that Provider(s) will order urine testing once or twice a year if I am on controlled medications.  I understand that controlled medications will not be renewed before the refill date, if it is lost, misplaced or stolen.  I might be asked to provide a police report in the event if any of the above occur.

I give consent to the provider(s) to access HCS in New York, CRISP in Maryland and PDMP in District of Columbia for Prescription data monitoring.

NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health.  This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”).  This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. 

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.  We are required to abide by the terms of this Notice of Privacy Practices.  We reserve the right to change the terms of our Notice of Privacy Practices at any time.  Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.

We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

We participate in the CRISP health information exchange (HIE) to share your medical records with your other health care providers and for other limited reasons. You have rights to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about CRISP medical record sharing policies at www.crisphealth.org.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

For Treatment.  Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services.  This includes consultation with clinical supervisors or other treatment team members.  We may disclose PHI to any other consultant only with your authorization.

For Payment.  We may use or disclose PHI so that we can receive payment for the treatment services provided to you.  This will only be done with your authorization. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. 

For Health Care Operations.  We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities.  For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.  For training or teaching purposes PHI will be disclosed only with your authorization. 

Required by Law.  Under the law, we must make disclosures of your PHI to you upon your request.  In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.

• Abuse and Neglect
• Judicial and Administrative Proceedings
• Emergencies
• Law Enforcement
• National Security
• Public Safety (Duty to Warn)

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

• Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding your personal PHI maintained by our office.  To exercise any of these rights, please submit your request in writing to the address above.

• Right of Access to Inspect and Copy.  You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care.  Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you.  We may charge a reasonable, cost-based fee for copies.
• Right to Amend.  If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures.  You have the right to request an accounting of certain of the disclosures that we make of your PHI.  We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations.  We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction. 
• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
• Breach Notification. If there is a breach of unsecured protected health information concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
• Right to a Copy of this Notice.  You have the right to a copy of this notice.
   

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing to Grace Manglet, DNP, or to the Secretary of Health & Human Services.

Consent: I hereby acknowledge that I have received and have been given an opportunity to print out a copy of of this Notice of Privacy Practices for my records. I understand that if I have any questions, I can contact the providers at Zohar Health by phone at (301) 250-0404.

MEDICAL HISTORY QUESTIONNAIRE

Health Care Providers

Emergency Contact