Consentimiento informado para la evaluación neuropsicológica y el tratamiento psicológico

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Rafael Alcaraz Navarrete
hace 7 años
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1 Rosalia Pereyra-Quiroz, Psy.D., MBA Clinical Psychologist Phoenix, AZ (602) Fax (602) Consentimiento informado para la evaluación neuropsicológica y el tratamiento psicológico La Dra. Rosalía Pereyra-Quiroz ha revisado verbalmente conmigo el propósito y la naturaleza de esta evaluación neuropsicologíca y/o tratamiento psicológico. La Dra. Rosalía Pereyra-Quiroz me han aconsejado que como resultado de esta evaluación, ella preparara un informe escrito acerca de mi presente funcionamiento neuropsicológico, hará una revisión de mi historia médica/psiquiatrica y dará una opinión profesional. Si la Dra. Rosalía Pereyra-Quiroz realiza una terapia cognoscitiva conductual ella me ha explicado sus implicancias y sus limitaciones. La Dra. Rosalía Pereyra-Quiroz ha discutido los honorarios profesionales conmigo, incluso el hecho de que debo de avisar a su oficina con 24 horas de anticipación sobre cualquier cancelación o ella podrá cobrarme por esta cita. La Dra. Rosalía Pereyra-Quiroz me han proporcionado con una copia de las prácticas de privacidad requeridas bajo HIPAA. La Dra. Rosalía Pereyra-Quiroz me ha avisado que ella tiene el deber de avisar a las autoridades pertinentes si es que les comunico que trato de infringir daños corporales a mi mismo o a otra persona. Esto se hace de acuerdo a las leyes y puede implicar la advertencia a la victima potencial. La Dra. Rosalía Pereyra-Quiroz también me han avisado que están obligada por la ley a informar de cualquier incidente que yo comunique en el que se sospeche abuso sexual o explotación de niños o adultos mayores. Firma del Paciente Fecha Fecha Firma del Examinador Fecha

2 AUTHORIZATION TO RELEASE MEDICAL RECORDS OF HEALTH INFORMATION Patient Name: Date of Birth: Patient Address: Street Apt. # City State Zip Code I authorize To release health information to: Phoenix, AZ (602) Fax (602) Information to be released: Discharge Summary EKG/ Progress Notes Operative Reports Radiology Reports Emergency Medicine Reports History and Physical Exams Diagnostic Imaging Reports Consultations The purpose of this release is (check one or more): Continuity of care or discharge planning Billing and payment of bill At the request of the patient / patient representative Other (state reason) Notice: Rosalia Pereyra, Psy.D. and many other organizations and individuals such as physicians, hospitals, and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. My rights: I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related treatment, 2) obtaining information in connection with eligibility or enrollment in a healthcare plan for 3) determining an

3 entity s obligation to pay a claim, or 4) creating health information to provide to a third party. Expiration of authorization Unless otherwise revoked, this authorization will expire 12 months after the date of signing this form. Signature: (Signature of Patient of Patient s Legal Representative) Date: (Printed Name) (If signed by someone other than the patient, state your legal relationship to the patient) (Witness or Translator)

4 Rosalia Pereyra, MBA, Psy.D. Clinical Psychologist Phoenix, AZ (602) Fax (602) Patient Information Form / Información del Paciente PATIENT S NAME NOMBRE DEL PACIENTE: DATE OF BIRTH SEX : MALE FEMALE FECHA DE NACIMIENTO: SEXO: HOMBRE MUJER PATIENT S SOCIAL SECURITY SEGURO SOCIAL DEL PACIENTE: ADDRESS DIRECCION: CITY STATE CIUDAD: ESTADO: ZIP CODE /CODIGO POSTAL TELEPHONE TELEFONO: MESSAGE MENSAJE NAME OF PERSON FINANCIALLY RESPONSIBLE NOMBRE DE LA PERSONA RESPONSABLE DE PAGO: PLACE OF EMPLOYMENT LUGAR DE EMPLEO: SOCIAL SECURITY DATE OF BIRTH SEGURO SOCIAL : FECHA DE NACIMIENTO IN CASE OF EMERGENCY CONTACT/ EN CASO DE EMERGENCIA CONTACTAR : NAME/NOMBRE:

5 ADDRESS/DIRECCION: TELEPHONE/TELEFONO: AUTHORIZATION TO PAY BENEFITS TO PSYCHOLOGIST: I hereby authorize direct payment to be made to Dr. Rosalia Pereyra, Psy.D. I understand Dr. Pereyra will file an insurance claim on my behalf as a courtesy; nevertheless, I am financially responsible for the charges not covered by my insurance company. I also understand that if my account is not paid by myself or by insurance company after sixty days from the date of service, it will be turned over to an independent collection agency and a $25.00 fee will be added to the account for processing charges. There will be a $25.00 service charge for any returned checks. I hereby certify that I do not have any other insurance carrier at this time. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Dr. Rosalia Pereyra, Psy.D. to release any information required in the course of my examination or treatment to insurance companies for payment. I hereby authorize photocopies of this form to be valid as the original. All releases are in accordance with HIPAA Privacy Rules. CONSENT OF TREATMENT: I (We), the patient /parent or guardian of the above named minor; authorize Dr. Rosalia Pereyra, Psy.D. and all persons acting as agents thereof to provide treatment to patient/the named minor. This consent shall remain in force until written revocation hereof is delivered to 2345 E. Thomas Rd. Suite A PHOENIX, AZ / Phoenix, AZ HIPAA Privacy Rule protects all information. SIGNED/FIRMA: DATE/FECHA: GUARDIAN) (PATIENT PARENT OR LEGAL WITNESS / TESTIGO:

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