logo
Sanjoy Sathpathy MD

Welcome to So Cal Psychiatric Care (SCPC)

Welcome to So Cal Psychiatric Care (SCPC)

We welcome you and your family members to out practice. We will do everything in our professional capacity to make the treatment as productive as possible. It is understood that all information between patient and Psychiatrist/Therapist is held strictly confidential and the Psychiatrist/Therapist will not release and information about therapy unless permitted by law or
  1. Is agreed upon in writing and complies with state law
  2. The patient presents an imminent danger to self or others
  3. Child/Adult neglect is suspected
  4. Is necessary for continuity of care
  5. A judge chooses to subpoena the records
  6. As requested by court appointed attorney for a child involved in court proceedings

PATIENT CONSENT TO RELEASE OF INFORMATION

I consent to information release about my (or my child’s) case with the referral source and co-treating  health care providers and facilities for purpose of treatment, payment and Health Care Operations. I further consent to the release of information to my health plan for claims, certification/ case management/ quality improvement and other health plan purposes.

GENERAL CONSENT FOR TREATMENT

I further authorize and request that my psychiatrist/therapist carry out psychological examinations, treatment and/or diagnostic procedures that now or during the course of my care as a patient are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may be at times difficult and uncomfortable.

GENERAL CONSENT FOR TREATMENT

On patient’s behalf, I (the legal guardian or Legal Representative) authorize SCPC to deliver mental health services to the patient. I understand that all policies stated on this page apply to the patient.

I accept that child’s records are confidential and that by law, I cannot have access to the child’s records if such access would be detrimental to the child.

CONSENT TO TREATMENT SIGNATURE

FINANCIAL TERMS AGREEMENT

a courtesy for me by billing my insurance company and it is ultimately my responsibility to know my insurance benefits and coverage. Upon verification of health plan/insurance coverage and policy limits, my insurance carrier will be billed for me and my provider will be paid directly by the carrier. SCPC will make every effort to assist me in getting my claims correctly, however, SCPC may need to contact me to have me help resolve claim issues with my insurance company. I will be responsible for any applicable deductibles and co-payments at the time of service. I agree to make these payments at each appointment. I do have the option of paying cash, due at time of service, and then billing my insurance company directly for reimbursement. I understand that if I am not eligible at the time services are rendered, I am responsible for payment, even if the determination is made after services are rendered.

I also understand I that will be responsible for a charge of $60 for any missed appointment if not cancelled prior to 48 hours of appointment time. SCPC will have access to my payment information so as to deduct the amount upon missed appointment. By signing this agreement I give permission to SCPC to deduct the amount as mentioned above.