Policy Statement

Confidentiality: All information that you disclose within psychotherapy sessions is confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. Disclosure may be required in the following circumstances:

• When there is reasonable suspicion of abuse of a child or an elder, including physical or sexual abuse, therapists are required to report this to officials who are responsible for investigating abuse.
• When there is reasonable suspicion that you may harm yourself or someone else, therapists are required to take steps to prevent harm to anyone.
• In a legal proceeding, when the judge issues a court order requiring release of records or testimony regarding psychological treatment.

In addition, billing heath insurance requires your authorization to release diagnostic code and procedure code information on the billing form. By signing below you give your permission for Toni Rabinowitz, Ph.D, LMFT to release this information as part of the process for billing insurance. You may also choose not to bill insurance.

If you have any questions concerning procedures for maintaining confidentiality or the limits of confidentiality, please ask me for a more detailed explanation.

Payment: Payment in full is due at the end of each session, unless other arrangements have been made. Client is wholly responsible for payment if insurance fails to reimburse. At your request and as a courtesy, we will bill your insurance plan for reimbursable services. However, it is your responsibility to follow up with insurance companies if you do not receive payment, or they do not respond. In that case we will provide you with a billing statement so you can resubmit the claim.

Procedure for Cancelling Appointments: If you are unable to keep your scheduled appointment and cancel at least 24 hours before the scheduled time, you will not be charged a cancellation fee. If you fail to cancel, or if you cancel within 24 hours of the scheduled time you will be charged $30 for the missed appointment the first time this occurs; and then the full fee after that. Please be aware that insurance companies will not pay for absences or late cancellations and will not be billed for these charges.

I have read and understand the above: