Billing

Authorization for the Release of Billing Information

Patient Name:*

Date of Birth:*

Email:*

I hereby authorize NYC Psychology Inc., PC to release the billing information to the following person(s) or facility(ies)

Consent

I do not wish to give authorization to release the information to any person(s) or facility(s).

Name*

Address*

Tel*

Email*

Relationship*

(Optional) Additional Facility/Person

Name

Address

Tel

Email

Relationship

(Optional) Additional Facility/Person

Name

Address

Tel

Email

Relationship

I understand that I may refuse to sign this authorization without affecting my eligibility for assessment and/or treatment. I further understand that I may withdraw this authorization at any time by submitting a written request to David H. Rosmarin PhD, 200 West 57th st, Suite 404, New York, NY 10019. Authorization may be withdrawn except to the extent that action has already been taken in reliance on this authorization. I further understand that information released on this authorization is no longer protected by NYC Psychology Inc., PC (e.g, if re-disclosed by recipient). To the extent to which my file contains information regarding alcohol and/or drug treatment (protected by Federal Regulations 42 CFR, Part 2) or HIV antibody/antigen testing (protected by NYS Law), I authorize disclosure of such information.

Signature*

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Authorization for the Release of Billing Information

I hereby authorize NYC Psychology Inc., PC to release the billing information to the following person(s) or facility(ies)

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