T TO T
I authorize, request, consent and agree to receive treatment /services from Cornerstone Therapy and
Wellness. I understand that I can withdraw this consent to treatment at any time. A withdrawal of consent will
be done in writing and will include the reason for withdrawal.
I understand that the office doe s not handle any of the following: work grievances, lawsuits, custody disputes,
disability determinati ons, or any other legal admi nistrati ve proceedings, including work excuses and request
for change in job con diti ons.
As the policy holder and/or patient fully understand that I am directly responsible for payment to C o r n e r s t o n e T h e r a p y
and Wellness for the entire services rendered to me. I also understand that my insurance is an
agreement between me and my insurance company. As a courtesy, Cornerstone Therapy and Wellness,
will file your insurance claims for me. For any reason, the submitted claims are not paid to them within 45 days
of the date of service, the policy holder and/or patient will become responsible for the entire bill. If such
an event does arise, an itemized bill will be given to me to help process my claims. This is a standard
practice within the Mental Health Industry.
I understand there is a fee for a copy of my record if the request comes from anyone other than another state
licensed physician or mental health practitioner. (M.D., LCSW, PsyD, LPC, etc.) This fee is outlined and
regulated by the PA Department of Health and is available on their web site. (www.health.pa.gov)
I understand that my physician will give me adequate prescriptions until my next scheduled visit and that is
my responsibility as the patient to make the next appointment in the correct time frame to be able to refill my
prescription. I also fully understand no refills will be given if I have not seen my physician within 90 days of
my last appointment. I also understand no re fi lls will be processed if I have missed or cancelled more than
one appointment. I understand that the office does not mail in prescriptions. I also understand controlled
substances prescriptions will not be replaced if lost or stolen
By my signature below, I acknowledge that I have read, understood and agree to all the above.
Signature: ________________________________________________________________________ Date:
and understand the documents fully.
and"Teletherapy Informed Consent"
and confirm that I
have had adequate opportunity to
"Electronic Communication Agreement,"
"Patients’ Rights and Responsibilities
I acknowledge that I have received from Cornerstone Therapy and Wellness, the
"Federal HIPAA Privacy
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