Forms to Download

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 HIPPA Form

 HIPPA AUTHORIZATION TO RELEASE AND/OR EXCHANGE INFORMATION NOTE: This authorization complies with the requirement of the HIPAA Privacy RuleUnless you explicitly notify me otherwise, I will generally assume that you wish your personal information to remain strictly confidential.If you are seeing a psychotherapist in addition to me, I will request your permission to coordinate your care with that person. I will also ask for permission to contact your primary care provider. This will allow all health care professionals to practice integrated care.Please note that insurance companies require a diagnosis and description of the psychiatric services rendered in order to cover the cost of your care.There are exceptions where I have a responsibility to release information, regardless of whether the patient agrees.These exceptions include:1) Cases of suspected child abuse or neglect are required to be reported to the State of Connecticut Department of Children and Families 2) Cases of suspected abuse or neglect of the elderly and mentally challenged are required to be reported to the State of Connecticut;3) The Courts of the State of Connecticut have a right to order Deborah S Greene APRN to release patient information;4) If I have reason to believe you are a direct threat of imminent harm to any individual (including yourself). In such a case the police will be notifiedBy signing, I acknowledge that I have received and reviewed a copy of this Notice of Privacy

 __________________________Patient Signature and Date

 Office Policies
Coverage: Since I am in solo practice, I am not always available by phone, and I do not have coverage when I am on vacation. If you require frequent telephone contact or have a history of requiring crisis management, I suggest you contact your insurance carrier to locate a provider who can better meet your needs. In case of psychiatric emergency please call 911, 211 or go immediately to your nearest emergency department. Please allow two business days for all phone calls to be returned. If the call lasts longer than 5 minutes the patient will be billed for $25.00 Office hours are conducted Tuesdays through Thursdays. All appointments are conducted via telehealth. Telehealth appointments are not conducted while the patient is in a car.Insurances: I accept Cigna, Aetna and traditional Medicare and fee-for service. If you have another insurance carrier, please contact the carrier to inquire if you have any out of network coverage. Please verify your coverage, deductibles, co-pay or co-insurance prior to your visits. If you require a form to be filled out an appointment is necessary in order to the form.. All fees are due at the time of the office visit. Medications: Please store all medications in a secure location. Early refills will not be provided. If you require a refill, please have your pharmacy contact my office. ALLOW THREE BUSINESS DAYS FOR REFILLS TO BE COMPLETED. To obtain refill prescriptons patients MUST be seen at a minimum of every three months. No exceptions will be made. NEW MEDICATIONS will not be prescribed over the phone. Patients who cancel scheduled appointments WILL NOT receive refills until they are seen in the office for assessment. Cancellation/Discharge Policy: Please provide a minimum of 48 hours’ notice if you need to cancel a previously scheduled appointment. You will be billed the cost of the appointment if you no show or cancel an office visit without 48 hours’ notice. All patients will be discharged after two cancellations. Patients must be seen at a minimum of every three months to remain an active patient  Patients are expected to be active participants in their treatment.


Patient Signature                Date  
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