Payment for Services and Insurance

Health Insurance
To use your health insurance for my services, you must verify with your insurance company  whether I accept your specific insurance plan. I currently accept many of the most common insurance plans. However, all insurers have different types of plans and I may not be in your specific plan that is offered by your employer. This is especially true with Kaiser Permanente and some of the heath plans sponsored by the trades.

Pay as you Go
If you are not using insurance, my cash rate is listed in my professional disclosure. My office can process credit card payments and checks. If you use cash, you must pay me directly (not my staff).

Your First Visit
To prepare for your appointment, you can download and complete the required forms.

• For the first telehealth appointment, you can return the forms via US Mail, or send them to  me via my Hushmail account (see the "Contact" page).  
  • There is a separate disclosure required for telehealth. This form needs to be initialed and returned before our first session. This form explains who the sessions are set up.
• For the first in-person you may bring the forms with you or send them to me ahead of time via my Hushmail account (see the "Contact" page).  
  • Due to the COVID 19 conditions, we ask that you do not arrive early to your in-person session, as we need to keep exposure to others in the waiting room to a minimum.

Keep in mind , in addition to the other paperwork, we need a photocopy of a government issued photo ID and your valid insurance card (if insurance is used)..

I do not accept, nor will I bill:

• Medicare, or Medicare secondary payer plans
• Medicaid type plans (e.g., Apple Health, Molina, Community Health Plan)
• Automobile insurance claims
• Employee Assistance Programs (EAP).

Client Forms

The forms listed below must be completed and or signed (unless you have questions), before your first visit.

1. New Client Intake - to be completed and signed. This can be completed electronically and printed using your computer.
2. Client Billing Information - to be completed and signed only if you want to use your health insurance to pay for services. This can be completed electronically and printed using your computer.
3. Professional Disclosure - initials (on each page) and a signature are needed. This can to be printed using your computer.
4. Agreement for Telehealth Services  - initials (on each page) and a signature are needed. This can to be printed using your computer. It is only needed if you want to do therapy on line or on the telephone.
5. Notice of Privacy Practices -  no signature is needed and it does not need to be returned. This is mostly FYI. 
6. DOH Brochure- no signature is needed and it does not need to be returned. This is mostly FYI. 

Due to legal and privacy considerations, do not return these forms via non-secure email or text.

Required Forms 

New Client Intake
​fillable form

Client Billing Information
​

3_client_billing_info_3.pdf
File Size:	52 kb
File Type:	pdf

Download File

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Professional Disclosure​

3_professional_disclosure_11_2020.pdf
File Size:	250 kb
File Type:	pdf

Download File

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Agreement for Telehealth Services

5_agreement_for_telehealth_services.pdf
File Size:	256 kb
File Type:	pdf

Download File

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These forms are For Your Information and do not need to be returned

Notice of Privacy Practices
​FYI

4_notice_of_pirvacy.pdf
File Size:	93 kb
File Type:	pdf

Download File

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Department of Health
Brochure, FYI

05_doh_brochure.pdf
File Size:	433 kb
File Type:	pdf

Download File

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Adobe Acrobat Reader
Use Adobe Acrobat Reader to view, download and complete these forms.
If you do not have Adobe Acrobat Reader, you can download it for free.

For Professionals