NAME OF PATIENT DATE OF BIRTH DATE ADDRESS PHONE (HOME) PHONE (CELL) INSURANCE INSURANCE INSURANCE NAME ID# GROUP#

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1 Michael Rosen, MD Board Certified American Board of Psychology and Neurology American Board of Medicine 2801 Buford Highway, Suite 505 Atlanta, GA (phone) * (fax) NAME OF PATIENT OF BIRTH ADDRESS PHONE (HOME) PHONE (CELL) INSURANCE INSURANCE INSURANCE NAME ID# GROUP# INSURANCE PHONE # (ON BACK OF INS CARD) POLICY HOLDER POLICY HOLDER POLICY HOLDER NAME OF BIRTH SS# NAMES & PHONE # s OF OTHER CURRENT PROVIDERS, PHYSICIANS LIST ANY MAJOR HEALTH PROBLEMS LIST CURRENT MEDICATIONS & DOSAGES PLEASE READ COMPLETELY, INITIAL WHERE INDICATED AND SIGN BELOW I understand that I am financially responsible for the charges incurred during treatment. I understand that I am expected to pay all fees not covered by insurance in full at the time of service, unless other payment arrangements have been made in advance. Fees include: Initial visit fee $225.00, 45 minute session $225.00, 30 minute session fee $150.00, 15 minute session fee $ PLEASE INITIAL CANCELLATION POLICY I understand that I am financially responsible for missed appointments that are cancelled less than 36 hours in advance. I further understand that my insurance will not reimburse me for this charge, and I will be responsible for the session fee. PLEASE INITIAL I authorize the release of any medical records or other information necessary to process an insurance claim. I further authorize payment of benefits directly to Michael Rosen, MD PC, when indicated. The office of Michael Rosen, MD PC, makes available his Privacy Practices Policy upon request. SIGNATURE OF PATIENT SIGNATURE OF PARENT/GUARDIAN (IF PATIENT IS A MINOR)

2 PATIENT INFORMED CONSENT AND OFFICE POLICY I have chosen to receive psychotherapy, medical and or medication treatment services from Michael Rosen, M.D. My choice has been voluntary and I understand that I may terminate therapy at any time. I authorize the release of any medical information necessary to process insurance claims for services rendered to me. For those individuals covered by any policy in which Dr. Rosen participates, I understand that I am financially responsible for co-payments, deductibles, and any other charges not covered by my insurance carrier. Co-payments are due at the time of service. I understand patients who are terminated from the practice by Dr. Rosen will be provided the following: --Referrals to other clinics and or providers. --Prescriptions for current medications Dr. Rosen is currently prescribing for the patient, which will include a onemonth refill. --SUNY Stony Brook CPEP phone number in the event that emergency care is required. I understand that records and information collected about my, or my child s treatments, will be held or released in accordance with state laws regarding confidentiality of such records and information. I understand that Dr. Rosen will not submit ANY out of network claims. If Dr. Rosen is not contracted with my insurance, I will be subject to the entire session fee at the time services are rendered, and any out of network claim submissions are my own responsibility. I understand that I am responsible for paying all fees incurred at the time services are rendered. For those on insurance, those fees include the co-payment or co-insurance and any unmet deductible (often seen at the beginning of the calendar year) based upon the fee schedule below. If I am not covered by insurance, or Dr. Rosen is out of network with my insurance I understand the fees are as follows: Initial intake: 45 minutes; 225 dollars Psychotherapy appointments: 45 minutes; 225 dollars Psychotherapy appointments: 30 minutes; 150 dollars Follow up appointments: 15 minutes; 85 dollars Due to increasing demand on time for non-clinical services, I understand that all patients (with or without insurance) will be billed for these other services if they cannot be completed at time of appointment. These include: 1. Paper work (e.g. SSI, school forms, work forms, letters) -- billed in 15-minute increments at 50 dollars each increment partially or completely used. I understand Dr. Rosen always tries to complete these forms at time of appointment for the patient s convenience and immediate return of the paperwork. Please plan your appointments accordingly. 2. Medication approvals -- also billed in 15-minute increments at 50 dollars each increment partially or completely used. (Please note, this can be time consuming, taking upwards of 45 minutes in some cases. I understand Dr. Rosen always, if appropriate, prescribes those medications not needing prior approval; this depends on each individual s plan). 3. Any past balances on my account must be paid in full at or by the next scheduled appointment with Dr. Rosen. I understand that if charges are refused, Dr. Rosen reserves the right to refuse to provide further services. All fees owed must be paid in full prior to further services, including prescription renewals.

3 Cancellation Policy: I understand that I am responsible for a portion of the session fee. If I cancel less than 36 hours prior to my or my child s appointment, I agree that I will pay the session fee in full, at or by the next scheduled visit with Dr. Rosen. I understand that if charges are refused, Dr. Rosen reserves the right to refuse to provide further services. All fees owed must be paid in full prior to further services, including prescription renewals. Copayment Responsibility: I understand that if for any reason a copayment is not received at the time of visit, it must be paid, in full, at or by the next scheduled appointment with Dr. Rosen. I understand that if charges are refused or not received, Dr. Rosen reserves the right to refuse to provide further services. All fees owed must be paid in full prior to further services, including prescription renewals. Bounced Checks: A bounced check will require a 50-dollar bounced check fee. Late Arrivals: The session time starts on time. If I am late, I understand I will only see Dr. Rosen during the remainder of the session time, and will be charged in full for the full session time. If Dr. Rosen is running late, I know I will get the full session time even though it will start late. Treatment Cooperation: I agree to follow the verbal treatment plan formulated by Dr. Rosen. If I do not follow the treatment plan, Dr. Rosen has the right to terminate treatment. I understand that it is my responsibility to report any change in my billing information or insurance coverage to Dr. Rosen. I hereby authorize Michael Rosen, MD to furnish required information to insurance carriers concerning my diagnosis and treatment. I understand that I am responsible for any amount not covered by my insurance and agree to pay interest on any past unpaid balance and or collection/attorney fee if the account is assigned to be enforced. I also hereby authorize Michael Rosen, MD to charge my credit card for any and all professional services rendered as described in this document. Please hold this active credit card on file for necessary charges, unpaid balances, medication approvals, and missed appointments as described above: Credit Card Type (Amex, Visa, MC, DISC): Credit Card Number: Expiration Date: Security Code: Billing Zip Code: Name of Card Holder: Signature of Card Holder: SIGNATURE OF PATIENT SIGNATURE OF PARENT/GUARDIAN (IF PATIENT IS A MINOR)

4 EMERGENCY CONTACT INFORMATION PATIENT NAME IN CASE OF EMERGENCY, PLEASE CONTACT: NAME: ADDRESS: PHONE NUMBERS: HOME WORK CELL RELATIONSHIP TO PATIENT THIS WILL BE PLACED IN YOUR FILE AND THE INDIVIDUAL WILL BE CONTACTED ONLY IN THE EVENT OF AN EMERGENCY. PLEASE NOTIFY DR. CONTOVASILIS IN THE EVENT THE CONTACT INFORMATION CHANGES. Consent Form (For the purposes of this consent, non- encrypted has the potential to be seen by unwanted or unintended third parties.) I, do herby consent to receive non encrypted from Dr. Michael Rosen M.D., or those designated by him at the following address, for the purpose of receiving documents, including but not limited to, education materials, new office policies, and symptom checklists so long as those documents do not contain any personal health information. I, do herby consent to receive non encrypted from Dr. Michael Rosen M.D., or those designated by him at the following address, for the purposes of both obtaining and communicating billing and/or insurance information which may contain minimal personal health data including but not limited to diagnosis, name, birth date, policy ID. I Further understand that all information I send in s to Dr. Michael Rosen and/or his designee(s) is not necessarily protected and that I am responsible for ensuring that s I send are protected if I so choose. (Most free hostings do not protect that are sent i.e. gmail, yahoo, aol etc.). Additionally I acknowledge I have been made aware that questions about medications, prescription refills, or about my treatment plan should not be submitted via , and that all such inquiries should be made by contacting Dr. Michael Rosen at his office at Patient signature Date

5 STATEMENT OF PRIVACY AND CONFIDENTIALITY IN MENTAL HEALTH SERVICES We are dedicated to preserving the confidentiality and privacy of all clients. Some state laws, however, specify certain circumstances when mental health professionals may be required to break confidentiality. Disclosure may occur: 1. If the client presents a clear and present danger to him/herself and refuses to accept appropriate treatment, the clinician may release relevant information to protect the client 2. If the clinician has a reasonable basis to believe that there is a clear and present danger of physical violence against a clearly identified or reasonably identifiable victim(s) (e.g., by history or client communication), relevant information may be released to protect the potential victim(s). 3. If there is a threat of imminently dangerous activity by the patient against him/herself or another person(s), the clinician may disclose client communications for the purpose of placing or retaining the client in a psychiatric hospital. 4. If the clinician, in his/her professional capacity has reasonable cause to believe that a child under the age of eighteen years is suffering serious physical or emotional injury resulting from abuse inflicted upon the child (including sexual abuse), or from neglect (including malnutrition), or who is determined to be dependent upon an addictive drug at birth, the clinician is required to report information to Child Protective Services of New York State or the appropriate department in another state where jurisdiction presides. 5.If the clinician has reasonable cause to believe that an elderly person (over age 60)or a handicapped or disabled person over the age of 18 has died or is suffering abuse, the clinician may be obligated to report this information to the proper state agency. 6. Information acquired by a clinician in the course of a professional practice may be disclosed to another appropriate professional within the organization as part of a professional consultation. 7. The clinician may provide diagnostic or treatment information to an insurance company or review board, hospital or medical service corporation, or health maintenance organization for the purpose of administration or provision of benefits and expenses. 8. If a judge compels the clinician to reveal confidential information or if the client initiates legal action (e.g. malpractice, criminal or license revocation) against the clinician, the clinician may disclose confidential client communications, if disclosure may be necessary or relevant to the clinician's defense. Apart from the above-listed exceptions, client Information may only be shared upon the express written consent of the patient or parent/guardian. I have read and understand the limits of confidentiality. I understand that I may discuss any of these limits with my clinician at any time. Patient name: Date of birth: Patient signature: Date: