New Patient Intake Form – Adults

Please only complete the form on this page if you answered "yes" to the above question.

In accordance with the health Insurance Portability & Accountability Act of 1996 ("HIPAA") which is a Federal Law, it is the policy of Dr. Cortman and/or members of his staff to not release confidential and/or unauthorized information. Dr. Cortman and/or members of his staff may leave medical information pertaining to my appointments on the telephone number(s) and/or by using the address provided on the intake information form. You will assume responsibility to notify Dr. Cortman and staff whenever this information changes. If you authorize healthcare information to be released to ANYONE ELSE, please complete the following:

In exhange for Dr. Cortman's and/or a member of his staff's agreement to prov ide professional serices, YOU AGREE TO PAY THE FEES for such services. Payment is due at the time services are provided unless other arrangements have been agreed to in writing prior to the services being provided. Availability of insurance coverage or the agreement of another person to be responsible for the payment of fees for services do not relieve you (or you on behalf of your minor child) of responsibility for the payment due. IF USING INSURANCE AND/OR MEDICARE, you authorize the release of any medical or other information necessary to process the claims for services provided and payment of medical benefits to Dr. Cortman and/or a member of his staff for the services provided. You AGREE TO PAY INTEREST at the rate of eighteen percent (18%) per year on any balance due which you fail to pay within sixty (60) days. You further agree that you will pay the costs of collection, including attorney's fees, if Dr. Cortman and/or a member of his staff must take any action to collect an overdue payment. THIS AGREEMENT SHALL REMAIN IN EFFECT until you (or your minor child) professional services rendered have been paid in full.

IF YOU NO-SHOW OR CANCEL YOUR APPOINTMENT WITH LESS THAN 24 HOURS NOTICE, YOU WILL BE CHARGED $100.00 FOR THE MISSED APPOINTMENT.

You will never be charged for a cancellation if it is made at least 24 hours in advance of your scheduled appointment time. Reason for this policy: Notifying us of your intention to cancel or reschedule 24 hours in advance gives us an opportunity to schedule someone else for that time slot. This is important because others may be on a wait list or may also be looking for an opportunity to reschedule for a different time. As much advance notice as possible is always appreciated.

This cancellation policy is standard in the medical and mental health fields and will be strictly enforced. On occasion, there will be understandable reasons for msising appointments, but exceptions to this policy will be rare.

Due to the Coronavirus outbreak, we are currently only offering telehealth sessions. Most insurance providers provide the same coverage for telehealth appointments as they would for comparable in-office visits. However, some plans may still refuse to cover telehealth visits, as this is is up to the insurance provider. We are in-network for Medicare and out-of-network for all other insurances. Although we accept most major insurance plans, we encourage telehealth patients to check with their insurance companies about telehealth coverage before their appointments. We DO NOT accept Medicaid, even as a secondary insurance.

Third party breaches are possible and these breaches are the largest associated risk with using telehealth services. We continue to follow ethical standards for privacy and confidentiality when using telehealth services. There should be no additional cost as a user of telehealth unless you have limited internet usage in your home. Please ensure the Wi-Fi connection you are using for telehealth services is password protected and secure. Telehealth services vary state by state. If you currently live outside of the state of Florida, your session may not be covered by insurance. You must let our staff know if you are not in Florida prior to scheduling an appointment. There are some potential benefits and risks of telehealth (e.g. miscommunication, missed non-verbal cues, household noise or interruptions, increased flexibility, convenience) that differ from in-person sessions. It is important during telehealth sessions that your clinician has a phone number where you can be reached if services are disconnected.

Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA "), you have certain rights to privacy regarding your protected health information. Your information can and maybe used to:

- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

- Chain payment from third-party payers.

- Conduct normal healthcare operations, such as quality assessments and physician certifications.

Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information is available upon request this organization has the right to contact its notice of privacy practices from time to time but you may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

Over the last two weeks, how often have you been bothered by the following problems?

Over the last two weeks, how often have you been bothered by any of the following problems?

Must be completed by all patients 65 years old or older