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