NOTE: Payment is expected at the time services are rendered. Failure to provide us the information requested may result in a reduction or denial of payment by your insurance.

Swati Ellendula, M.D. is hereby released from any and all liability arising out of, or in any way incidental to, producing records or providing information pursuant to this authorization. (A duplicate, photostatic copy or facsimile reproduction of this authorization may be used in lieu of the original.) This authorization is subject to revocation in writing only by the undersigned.

Please check the box next to each statement below to confirm you have read, understood and initial it.

Your calls are welcomed and we will return them promptly during business hours. We do not have an after-hours answering service. You must call the office and leave a voice mail. If you need to make an appointment please call during our business hours. If you have an emergency please call 911 or go to the nearest Emergency Room.

I do hereby consent and authorize Thrive Psychiatry and Wellness to release all information contained in my financial and medical records, including diagnoses and test results, to my insurance company or health plan, their agents and independent contractors, or any other person or entity that is responsible for paying or processing for payment any portion of my bill, for the purposes of administration, billing and quality and risk management. This consent applies to all records created in the course of and relating to my treatment and for the purpose of reimbursement for treatment.

I understand that I may revoke this consent at any time by giving written notice to Thrive Psychiatry and Wellness except to the extent that action has been taken in reliance thereon. If no prior notice of revocation is received, this consent will expire six (6) months after the date of patient discharge from treatment, unless another date or condition is specified. I understand that if I refuse to consent to this Release of Information, the consequences will be that the insurance claim will not be filed.

I hereby authorize my or my child's insurance company to pay directly to Thrive Psychiatry and Wellness / Swati Ellendula, M.D. any insurance benefits otherwise payable to me or my child, if any by reason of the services described in the itemized statement rendered, and subject to the terms and limitations found in my insurance policy with the aforementioned company. This is a direct assignment of rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assigned, and I have agreed to pay in a current manner any balance of said professional service charges over and above this insurance payment. A photocopy of this assignmentshall be considered as effective and valid as the original.

Notice to Receiving Agency/Person: This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The Federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug use patient.

• To be treated with dignity and addressed in a respectful manner.
• Consistent, quality care by qualified and trained professionals in a clean and safe setting.
• Humane care and treatment free of abuse, neglect, humiliation, threats or exploitation.
• Privacy of your treatment and your records.
• To be informed of risk, benefits and alternatives to medications and/or therapy.
• To consult with another licensed practitioner at your own expense.
• To make a complaint or grievance.
• The same legal rights and responsibilities as all citizens, unless otherwise indicated by law.
• The right to be free from discrimination due to race, color, religion, national origin, gender, disability, sexual orientation or marital status.

• Please notify your provider immediately of any concerns, questions or feedback you may have regarding your sessions and your care.
• Keep appointments and when unable to do so for any reason, notify your counselor or physician's office with at least 24 hours' notice prior to your appointment. You will be charged $75.00 for appointment cancellations without 24 hour notice.
• To pay a fee of $15.00 for any medications if required on the same day.
• To pay a fee of $30.00 for treatment reports you request on your behalf and/or for copies of your records.
• All co-pays, fees or charges will be collected at the time of service. There is a $30.00 fee for all returned checks.
• To maintain a clean and safe office environment. Avoid bringing any food or drinks into the clinic.
• To maintain safe settings by not bringing weapons, non-prescribed drugs or alcohol on the premises of the clinic.
• Treat your provider, office staff and furnishings with respect and follow all posted office rules.
• Maintain supervision and responsibility for your children and family while in the office.
• Pay for any damages caused by the careless, reckless or intentional behavior of you or your family members.
• Provide accurate and complete information about current problems, past illnesses and treatments and other pertinent information.
• Inform us if you are receiving counseling, medications or other therapeutic services from another clinician.
• Participate in treatment decisions and follow the agreed upon plan or recommendations.
• Check with your counselor or physician's office about your appointment if inclement weather is forecasted.
• You may be referred to another provider for failing to follow these responsibilities.

I acknowledge that I have reviewed and was given the opportunity to receive a copy of these Rights and Responsibilities.

1. I understand that the medication I am prescribed for ADHD is a Class II Narcotic and the medication I am prescribed for sleep, anxiety is a Class IV narcotic.
2. I understand that the medication cannot be refilled before thirty (30) days.
3. I understand that if I lose my prescription, I will have to wait until the last due date from the original due date the last prescription was written for a refill.
4. I understand the medication is for my use only and cannot be shared with anyone else.
5. I understand that I am subject to random drug testing.
6. I understand that I will only take the medication as prescribed.
7. I understand that I cannot take illegal street drugs with this medication and if illegal drugs are found in my system with drug testing this medication will not be renewed by my provider.