I authorize Dr. Glenda Martinez, licensed clinical psychologist by the state of Florida, to provide diagnostic testing and/or psychotherapeutic services as required. I understand that I may withdraw my consent, at any time to the extent permitted by law. I have the right to confidentiality with telehealth under the same laws that protect the confidentiality of my medical information for in-person service. Any information disclosed by me during the course of my session is generally confidential.

POLICY ON CONFIDENTIALITY OF INFORMATION (LIVE AND TELEHEALTH)

Any communication between Dr. Glenda Martinez and her patients or clients shall be confidential and shall not be disclosed to anyone without expressed written permission or a court order. However, this privilege may be waived under the following conditions:

1. When there is clear and immediate probability of physical harm to the patient or the client, to other individuals or to society and Dr. Glenda Martinez communicates the information only to the potential victim, appropriate family member, law enforcement or other appropriate authorities.
   
   
2. Information disclosed regarding abuse of any protected group will be reported according to the guidelines specified by Florida Law.
   
3. If Dr. Glenda Martinez is a party defendant to civil criminal, or disciplinary action arising from a complaint filed by the patient, client or said representative, in which case the waiver of confidentiality shall be limited to that action.
   
   
4. When the patient or client agrees to the waiver, in writing, or when more than one person in a family is receiving therapy, when each family agrees to the waiver in writing.
   
   
5. When the patient or client is using national, state or private insurance, group insurance or any other type of third party payers to pay for services received from Dr. Glenda Martinez said organization requires information for the purposes of determining eligibility for payment. In such cases, care will be taken to protect the client or patient in providing only required information.
   
   
6. In the event that Dr. Glenda Martinez cannot continue practicing due to debilitating illness or death, they will establish an agreement with local mental health professional to ensure the continuity in confidentiality and security of the patient records and will thereby assign the privilege to said mental health professional.
   
   
7. I understand that while service have been found to be effective in treating a wide range of mental disorders and personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from telehealth, results cannot be guaranteed or assured.
   
   
8. I understand that telehealth treatment is different from in-person therapy/consultation and that if my provider believes I would be better served by another form of service, such as in-person treatment, I will be referred to a provider in my geographic area for such services.
   
   
9. I accept that telehealth does not provide emergency services. During our first Telehealth session, my provider will discuss an emergency response plan, which will include contacting the
   listed emergency contact and/or 911 for the address listed. If I am experiencing an emergency situation, I understand I can call 911 or proceed to the nearest hospital emergency room. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273 TALK (8255) for free 24-hour hotline support.
   
   
10. I understand I am responsible for 1) providing the necessary computer, telecommunications equipment, and internet access for my telehealth sessions; 2) maintaining the information security on my computer; and 3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telehealth session.
    
    
11. I understand that I cannot be driving at the time of my session. If I am to take my telehealth session within my vehicle, I must be parked.
    
    
12. I understand that it is my responsibility as the client to call my insurance company and ask if the benefits under my plan cover telehealth and telemedicine sessions.

 

I hereby authorize payment directly to Glenda Martinez, Ph.D., of benefits due to me from my insurance company otherwise payable to me. I further authorize the release of any medical information required by my insurance carrier (s) and/or Glenda Martinez, Ph.D. A copy of this authorization may be in lieu of the original. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carries any information needed for this or a related Medicare claim. I request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand that I am financially responsible for charges not covered by this authorization.

We are a participating provider with many insurance carriers, and we will file claims on your behalf if services are a covered benefit. You will be responsible for non-covered services and any services beyond your benefits maximum. If you have dual coverage, and we do not participate with your primary insurance, this office reserves the right to request that services must be paid in full at the times services are incurred. You authorize Glenda Martinez, Ph., P.A. to obtain insurance benefits, submit claims, and receive payments of medical and behavioral health benefits on my behalf.

You must also advise us when you insurance information changes prior to the time of service. This is important because insurance companies often have time limits for filing claims and obtaining authorizations. Therefore, if you fail to notify us you may lose important benefits because we cannot file claims to your new insurance if it is outside your new insurance company’s timely filing limits. If your coverage changes under your new insurance, you will financially responsible for services rendered that are not covered under your new insurance, even if such services were covered under your prior coverage. In case that the patient’s policy changes or is terminated, or if coverage is transferred to another insurance company, the patient will notify Dr. Glenda Martinez, P.A. immediately. The patient will also provide the new insurance information prior to the scheduled appointment to the business office so benefits can be called in and potential authorization can be obtained. A copy of the new insurance card will also be submitted at the first visit utilizing that coverage.

Payment by the insurance company cannot be guaranteed. The patient understand his/her responsibility to meet any deductibles and pay any co-payments and/or coinsurance as determined by my benefits. The patient is responsible for this amount at each scheduled appointment. Co-payments, co-insurance and deposits are required prior to the time of service. Patients without insurance coverage are required to pay in full prior to the services being rendered. For your convenience, we accept the various forms of payment. If you pay with a check and the check is returned, you will be responsible for a $35 returned check fee and $25 administration fee. If I have not met the deductible on my insurance plan, I agree to pay the contracted rate of the insurance until the deductible is met. If necessary, this office will submit the paperwork for authorization of additional sessions. These fees may not apply to psychological testing. If psychological testing is recommended, Dr. Martinez will discuss the fees with you

The patient understands that many insurance plans may have a certain number of limited therapy sessions per year. That coverage may also require additional authorizations routinely. The patient understands that the number of visits allotted is for all accrued visits from any behavioral health provider seen. Should the patient’s benefits exhaust, the provider will do her best to help continuity of care and offer me an alternative fee arrangements and or link you to a community outreach center. If the patient receive payments directly from the insurance company, he/she will immediately submit these payments to Dr. Glenda Martinez, P.A. In the event that the insurance company misquoted the patient’s benefits, benefits changed, or refuses to make payment, the patient will be responsible for all unpaid balances. If the carrier reevaluates my benefits even after a payment is made and requests a refund for that amount due to a processing error, an inactive policy, a preexisting condition, or other explanation, the patient is responsible for making payment to Dr. Glenda Martinez, P.A. in the amount of the refund in a prompt manner.

Disclosure of confidential information may be required by the patient’s health insurance carrier or managed care company. Information often requested includes dates/time of services, types of procedures, diagnosis and its manifestations, treatment plans, and progress of therapy. If it is the case that the insurance company utilizes a managed care company, the provider may need to discuss treatment with a case manager and/or at times dispense case notes and summaries. Thus, confidentiality may be compromised in such a case which is a necessity in the efforts to secure ongoing care. The provider has no control or knowledge over what insurance companies do with the information submitted or who has access to this information.

The patient understands a charge of $55 will be required for any appointment not cancelled 24 hours in advance. You may call the office 305-826-6969 or email drglendamartinez@gmail.com in order to cancel. The patient understands that since the appointment has been reserved  exclusively f or him or her, it is required to cancel or reschedule appointments at least 24 hours to avoid being charged. Insurance company will not pay for missed appointments.

Dr. Martinez does not provide on-call service. If I need to contact Dr. Martinez between sessions, I will leave a message and she will return my call in a timely manner. If a case of an emergency should arise in which I believe that I am a danger to myself or others or my child may be a danger to him/herself or other, I must call 911, go to the nearest emergency room, or call National Suicide Prevention Lifeline at 1 800-273- TALK (8255). I agree to a Co-pay/fee for the consultation session and subsequent 45 minute psychotherapy sessions

The following services are not covered by insurance and the fees are due when the time is schedule:
1) Consultations/meetings with school officials are charged at $150 portal to portal. This includes letters or treatment summaries.
2) Legal-related work such as depositions, witness testimony, reports, letters, etc. are charged at $500 per hour, portal to portal.
3) Copies of records are charged at $1.00 per page, plus necessary postage.

The federal government mandated that all health care patients are to receive from their clinician a notice (hereafter referred to a “Notice”) regarding the protection of their private health care information in compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule. The undersigned acknowledges receipt of a copy of the currently effective Notice of the Privacy Notice either by web, e-mail, US mail, or in person as required by the federal government’s HIPAA legislation. HIPAA covers what is called “protected health information” (PHI) that it is used for treatment, payment and health care operations. PHI is information in your health record that could identify you. All providers and/or Glenda Martinez, Ph.D. maintain paper and/or electronic records describing the patient’s health history, symptoms, examinations and test results, diagnosis, treatment and any plans for future care of treatment.

I understand that I as a patient may revoke this consent in writing. I understand that by refusing to sign this consent or revoking this consent, my provider may refuse to treat me as permitted by section 164.506 of the Code of Federal Regulations. I further understand that Glenda Martinez, Ph.D. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should my provider Glenda Martinez, Ph.D., change their notice, they will send a copy of any revised notice to the address I have provided.

 

A copy of this signed, dated acknowledgement shall be as effective as the original. The signature on this form also acknowledges that I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. I understand that if I have any questions about this form, or the HIPAA Notice, I will contact the privacy office, Glenda Martinez

I understand that the specific information to be released and exchanged may include, but is not limited to: history, diagnosis, treatment of drug or alcohol abuse protected under 42 U.S.C. 290dd2 and 397.501, Fla. Stat..., treatment of mental illness protected under 394.4615, Fla. Stat., of communicable diseases, including human immunodeficiency virus (HIV) and acquired immune Deficiency Syndrome (AIDS) protected under 381.004, Fla. Stat, as well as, educational/ school records, if such information exists. I understand that the information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected under this agreement. I understand that per HIPAA rule Dr. Martinez have 30 days to process the release of information.

I understand that I have the right to revoke this Authorization, except to the extent the Dr. Martinez has already used or disclosed the information prior to the receipt of the revocation. The request to revoke the Authorization must be made in writing and submitted to Dr. Martinez.

I have read and understand the consent and I have signed it voluntarily and of my own free will.