Rebecca Twersky, MD Psychiatry
Rebecca Twersky, MD Psychiatry
Integrated Psychotherapy, Psychopharmacology, and Psychoanalysis

Forms

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Surprise Fee

New York state's  "Surprise Fee" law, requires that physicians inform patients of participation in insurance plans, fees, and hospital affiliations.

Click Here to See the Surprise Fee Form

 

Release of Information

If you'd like me to send all or part of your written health information to someone, you can print and fill out this form, which gives me permission to do so.

Click Here to See and Print the Release of Information Form

 

Current Fees

Click the link below to see a list of my fees. I have a sliding scale fee system, which means that if you can't afford my fee using a combination of your own resources and any insurance coverage you have, we can try to negotiate a lower fee. If we can't find a mutually agreeable fee, I will do my best to refer you to a treatment you can better afford.

Click Here to See My Current Fees

 

 

Claims History

With your permission, I can check your prescription claims history, to see what medications you are currently taking, or have taken recently. This is not required-it simply makes it easier to write new prescriptions for your current medications. Please note that you can revoke your permission at any time. 

 

Click here to See and Print the Claims History Form

 

Consent to Disclose Information

If you'd like me to speak with your doctor or therapist, or a family member, you can print and fill out this form.

Click Here to See and Print the Consent to Disclose Information Form