Insurance Information
Primary Insurance
Secondary Insurance (if applicable)
Tertiary Insurance (if applicable)
Insurance card(s) must be provided prior to the first appointment by secure upload, encrypted transmission where available, or in person. Submission via standard email is not secure.
Informed Consent & Practice Policies
Informed Consent for Psychological Services
Psychological services include evaluation, diagnosis, consultation, and treatment of mental and behavioral health conditions. Interventions may include structured psychological procedures, assessment measures, and coordination with medical providers as clinically indicated. No guarantee of outcome is made. Participation is voluntary and may be discontinued at any time. Mandated reporting laws require disclosure when there is risk of harm to self or others, suspected abuse or neglect, or as otherwise required by law.
Crisis and Emergency Limitation
This practice does not provide emergency services. In the event of an emergency, contact 911 or 988 immediately. Do not use email, SMS, or portal communication for urgent or crisis matters.
No Surprises Act — Good Faith Estimate
You have the right to receive a Good Faith Estimate of expected charges if uninsured, self-pay, or electing not to use insurance. You may request this estimate at any time. Dispute procedures are available if charges substantially exceed the estimate.
Fees and Payment Policy
Payment is due at the time of service unless covered by contractual insurance agreement. Accepted payment methods include credit and debit cards. Card-on-file authorization is required. By signing this agreement, the patient authorizes charges for copayments, deductibles, coinsurance, missed appointment fees, and outstanding balances. The patient remains financially responsible for all non-covered services. Unpaid balances may be referred to collections. VA patients are not responsible for payment for authorized services.
Cancellation and Attendance Policy
Minimum 24-hour notice is required for cancellation. Late cancellations or missed appointments incur a fee. Repeated non-attendance or rescheduling may result in discharge from services.
Electronic Communication Consent
Electronic communication, including SMS and email, is not fully secure and may be subject to unauthorized access. These methods are limited to administrative communication unless otherwise agreed. By consenting, the patient acknowledges and accepts these risks.
Consent to electronic communication
Recording Policy
Recording of sessions is prohibited without prior written authorization. Unauthorized recording may violate applicable state law, including two-party consent requirements, and may result in termination of services.
Telehealth Informed Consent
Telehealth utilizes secure communication systems. Risks include technical failure, transmission limitations, and potential privacy risks. Patient responsibilities include maintaining a private setting, secure connection, and providing current physical location and emergency contact at each session. Services may only be provided when the patient is located in a state where the provider is licensed.
Consent to telehealth services
Digital Tools Disclosure
Secure digital systems may be utilized for documentation and scoring functions. These tools do not independently determine diagnosis or treatment. All clinical determinations are made solely by the licensed psychologist.
Notice of HIPAA Privacy Practices
Effective Date: April 3, 2026
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Atomic Shrink Psychology, Inc. is a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) and complies with all applicable federal and state privacy laws, including the California Confidentiality of Medical Information Act (CMIA), the Texas Medical Records Privacy Act, and applicable Colorado statutes. Where state law provides greater protection than federal law, the more stringent standard governs.
Protected Health Information (PHI) includes all individually identifiable health information in any form, including electronic, paper, and oral formats, relating to your past, present, or future physical or mental health condition, the provision of care, or payment for care.
OUR LEGAL DUTIES
We are required to maintain the privacy and security of your PHI, provide you with this Notice, abide by its terms, and notify you following a breach of unsecured PHI without unreasonable delay and no later than 60 calendar days from discovery. Notification may be provided by written notice, electronic communication where appropriate, or substitute notice as permitted by law. We reserve the right to revise this Notice at any time. Any revision will apply to all PHI maintained by this practice and will be made available upon request.
PERMITTED USES AND DISCLOSURES
PHI may be used and disclosed without additional authorization for purposes of treatment, payment, and healthcare operations. This includes coordination of care, consultation with other providers, billing, insurance verification, utilization review, administrative functions, quality assurance, and professional oversight activities. PHI may be disclosed to contracted business associates who perform services on behalf of the practice and who are bound by written agreements requiring protection of the privacy and security of such information.
SPECIAL DISCLOSURES
PHI may be disclosed as required by federal or state law, including but not limited to mandatory reporting of child abuse, elder abuse, or dependent adult abuse; compliance with court orders, subpoenas, or legal processes; law enforcement requests; public health reporting; workers’ compensation claims; and the prevention of serious and imminent threats to health or safety.
DISCLOSURES REQUIRING AUTHORIZATION
Written authorization is required for disclosure of psychotherapy notes except where permitted by law, use of PHI for marketing purposes where applicable, and sale of PHI. Authorization may be revoked in writing at any time except to the extent that reliance has already occurred. Psychotherapy notes are maintained separately from the general medical record and receive additional protection under federal law.
YOUR RIGHTS
You have the right to inspect and obtain copies of your PHI, request amendment of inaccurate or incomplete information, receive an accounting of certain disclosures, request restrictions on uses or disclosures, and request confidential communications by alternative means or locations. You have the right to request restriction of disclosure of PHI to a health plan when the service has been paid in full out-of-pocket. This request will be honored as required by law. You have the right to obtain a paper copy of this Notice upon request.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with Atomic Shrink Psychology, Inc. or with:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
You will not be retaliated against for filing a complaint.
HIPAA Acknowledgment
The patient acknowledges receipt of the Notice of Privacy Practices