Informed Consent for Disclosure

I hereby give permission for Integrated Psychological Services LLC or Jeff Gedney, PsyD to:

1.) Communicate either verbally or in writing with those listed below. You may revoke your consent for communication at any time, however it is strongly suggested that you first discuss this with your other care provider(s) as it may affect the provision of services.

It is understood that only personal health information relevant and necessary for the planning, coordination and provision of appropriate treatment or services will be disclosed. Information will be treated as confidential in accordance with practice standards and HIPAA compliance guidelines. While every effort will be made to properly protect your personal health information, the releaser cannot be liable for the protection of such information after it has been provided to the authorized recipient.

Under law, the following exceptions to confidentiality may apply:

– A judge may order my testimony if he/she determines that the issues demand it.

– There is evidence of threat of serious bodily harm to self or to another or there is evidence that a child, elderly person or disabled person is being abused. Under these situations I am required to take protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

2.) File insurance claims, either written or electronic, for payment of services:

It is understood that Copayments or deductible are due at the time of service. You are responsible for any remaining balance not covered by your insurance policy. A filed insurance claim does not guarantee payment. Insurance payments may take several months so you may not receive a final invoice until after that time. A 15% late fee may be assessed on payments received more than 30 days after the invoice date. I reserve the right to submit unpaid bills to a collection agency or small claims court. If so, your personal information will be protected to the best of my ability however you will be responsible incurred fees.

I acknowledge that a paper copy of the HIPAA Notice of Privacy Practices has been made available to me (this form is also available at: www.ipsyservices.net) and that I have been provided the opportunity to ask questions and discuss this consent to my satisfaction.

Signature: Date:

(Valid for 12 months)

Printed Name:

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