Release of Information Consent for Insurance:
My signature below authorizes Innovative Psychological Consultants to exchange information with my current health insurance carrier in order to facilitate claims payment. I understand they will need to release my demographics, dates of service, diagnoses, and possibly my treatment plan
and supporting information. I realize I can withdraw my consent at any time.
My signature below indicates that I have read, received, and understand the limits of confidentiality for clients and healthcare providers in Minnesota.
My signature below indicates that I have been provided a copy of the Informed Consent Agreement. My signature below confirms my understanding of all the rules and responsibilities of both the client and the clinician. I have been informed and agree to adhere to the no show and late cancellation policy. My signature constitutes
my agreement and compliance with the document.
Federal Guidelines on Confidentiality:
Please indicate below whether you would like a copy of the Federal guidelines on confidentiality:
Health Insurance Portability & Accountability Act (HIPAA).
Communication with Primary Care Physician:
Many clients, and insurers, like their clinicians to communicate and share information with primary care physicians. Please indicate below if you would like us to contact and send a copy of your assessment to your physician.