New Patient Paperwork

1 Patient Info
2 Spouse/Guardian
3 Services Contract
4 Cancellation
5 Medications
6 Sleepiness
7 Anxiety
8 Depression
9 Disclosure
10 Telehealth
11 Privacy
12 Medicare Opt Out

Patient Registration Information

Fields marked with * are required.

Patient Information

Spouse & Guardian Information

Spouse Information (if applicable)

Guardian/Legal Representative Information (if applicable)

Outpatient Services Contract

Please read the following document carefully. (Rev. 01/2025)

Welcome to the independent practice of Dr. Stephanie Silberman. This document contains important information about my professional services and business policies. Please read it carefully and note any questions you might have, so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

PSYCHOLOGICAL AND SLEEP DISORDERS SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, as well as the particular problems you bring forward. There are many different methods I may use to deal with the problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on issues both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

MEETINGS

I conduct an evaluation that will last from 1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one appointment (45 minutes duration) per week at a time we agree upon. Once an appointment is scheduled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation if your appointment is on a Tuesday through Friday and 72 hours advance notice if your appointment is on a Monday — unless we both agree that you were unable to attend due to circumstances beyond your control.

CONTACTING ME

I am often not immediately available by telephone, because I will not answer the phone when with a patient. When I am unavailable, my voicemail system will provide a direct and confidential means of contacting me. When you leave a message, I will try to return your call as soon as possible. Please call during normal business hours whenever possible. I will make every effort to return your call on the same day you leave a message. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If there is a life-threatening emergency, call 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a psychotherapist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if s(he) determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child is being abused, neglected, and/or abandoned; or an elderly or disabled person is being abused, neglected, or exploited, I must file a report with the appropriate state agency.

If I believe that a patient is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If such a situation occurs, I will make every effort to fully discuss it with you before taking any action.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to your therapy.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice from an attorney may be needed because the laws governing confidentiality are quite complex.

PROFESSIONAL RECORDS

I am required to keep records of the professional services I provide, as you may be aware. Because these records contain information that can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them. However, I will provide, at your request, a treatment summary unless I believe that doing so would be emotionally harmful. If that is the case, I will be happy to send the summary to another mental health professional who is working with you. This service will be provided without any additional charge.

MINORS

If you are under eighteen years of age, please be aware that the law provides your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a verbal summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.

PROFESSIONAL FEES

My fee is $250.00 per session. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost in increments of 15 minutes if I work for periods of less than one session hour (45 minutes). Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $500.00 per hour for preparation and attendance at any legal proceeding or for any forensic-related cases.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT

I am not in-network with any commercial or governmental health insurance companies. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a commercial health insurance policy, it may provide some coverage for mental health treatment. Upon request, I will provide you with an invoice of services rendered that you can send to your commercial insurance company for reimbursement; however, you (not your insurance company) are responsible for full payment of my fees at the time of service. It is very important that you find out exactly what mental health services your insurance policy covers. Since I have opted-out of Medicare, please note that Medicare will not reimburse you for my services, and therefore you are fully responsible for paying the fees at the time of service.

I, , have read and understood Dr. Silberman's 4-page “Outpatient Services Contract” (Rev. 1/2025). Among other things, this document explains what I can expect in receiving psychological services; the risks associated with this service; information about scheduled appointments and missed appointments; how to contact my therapist; confidentiality and its limits; the management and access to professional records; special issues when service is delivered to minors; professional fees for which I am responsible; billing practices and payment expectations; and issues related to insurance reimbursement.

My signature below indicates that I agree to abide by the document's terms during my professional relationship with Dr. Silberman, and that I consent to treatment.

Additionally, my signature below indicates that I understand that Stephanie Silberman, Ph.D., is an independent practitioner at Broward Pulmonary and Sleep Specialists and that no other service provider at the center, unless I have specifically contracted with them, is involved in my care and/or the treatment I receive.

Cancellation Policy

All cancellations for appointments must be made 24 hours in advance, unless you have a Monday appointment, in which case 72 hours advance notice is required (by the Friday before).

If you do not cancel within this time period, you will be charged the full fee for the missed session.

Initial and/or follow-up appointments: $250

Current Medications

Please list all medications you are currently taking.

Prescription Medications (Rx)

Medication Name Amount/Dosage When Taken What For (Purpose) Prescribing Doctor

Over-the-Counter Medications (OTC)

Medication Name Amount/Dosage When Taken

Herbs

Name Amount When Taken

Vitamins

Name Amount When Taken

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.

0 = Would never doze    1 = Slight chance of dozing    2 = Moderate chance of dozing    3 = High chance of dozing

1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place (e.g., a theater or a meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic
Total Score: 0 / 24

0–10 Normal  |  11–14 Mild sleepiness  |  15–17 Moderate  |  18–24 Severe

Beck Anxiety Inventory

Below is a list of common symptoms of anxiety. Please indicate how much you have been bothered by each symptom during the past month, including today.

0 = Not at all    1 = Mildly (it did not bother me much)    2 = Moderately (it was very unpleasant but I could stand it)    3 = Severely (I could barely stand it)

1. Numbness or tingling
2. Feeling hot
3. Wobbliness in legs
4. Unable to relax
5. Fear of worst happening
6. Dizzy or lightheaded
7. Heart pounding / racing
8. Unsteady
9. Terrified or afraid
10. Nervous
11. Feeling of choking
12. Hands trembling
13. Shaky / unsteady
14. Fear of losing control
15. Difficulty in breathing
16. Fear of dying
17. Scared
18. Indigestion
19. Faint / lightheaded
20. Face flushed
21. Hot / cold sweats
Total Score: 0 / 63

0–21 Low anxiety  |  22–35 Moderate anxiety  |  36–63 Potentially concerning

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

0 = Not at all    1 = Several days    2 = More than half the days    3 = Nearly every day

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
Total Score: 0 / 27

0–4 Minimal  |  5–9 Mild  |  10–14 Moderate  |  15–19 Moderately severe  |  20–27 Severe

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Disclosure Authorization Form

This form authorizes Stephanie Silberman, Ph.D. to disclose or obtain your information. Complete only if applicable.

Physician / Provider Information

Information to be Disclosed

Check each item to be disclosed:

Purpose

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Stephanie Silberman, Ph.D. at 10059 NW 1st Ct, Plantation, FL, 33324. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration

Unless sooner revoked, this consent expires 60 days from date of signature or upon completion of treatment, whichever is later.

Conditions

I further understand that Stephanie Silberman, Ph.D. will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may limit the ability to collaborate with other treating providers.

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Redisclosure

Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances: to improve the quality of care.

I will be given a copy of this authorization for my records, if requested.

Informed Consent for Telepsychological Services

In addition to agreements made in the Contract for Services, we will need to agree to the following, prior to starting video-conferencing services:

  • There are potential benefits and risks of video-conferencing that differ from in-person sessions. Benefits include being able to continue treatment when obstacles prevent in-person sessions. Risks include limits to patient confidentiality as someone may be able to overhear our conversation if you are not in a private place.
  • Confidentiality still applies for telepsychology services and our sessions will not be recorded.
  • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session and use a secure internet connection (rather than a public/free wifi).
  • We agree to use the video-conferencing platform I have selected for our telemedicine sessions, and I will explain how to use it. You need to use a webcam on your computer, smartphone or other electronic device during the session.
  • It is important to use a secure internet connection rather than public/free Wi-Fi.

If we have technical difficulty, I will call you at the number you provide to me. If we have significant difficulty connecting, I will not charge you for the session.

By signing below, I am consenting to telepsychological services with Dr. Silberman. I understand that any of the points mentioned above can be discussed and may be open to change by either of us at any time.

Notice of Privacy Practices

Please read the following Notice of Privacy Practices carefully.

NOTICE OF PRIVACY PRACTICES:
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact me at (954) 873-6683. Written requests should be addressed to: Dr. Stephanie Silberman, 10059 NW 1st Ct, Plantation, FL 33324.

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). Please retain these pages (inclusive of this one) for your records.

ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE

You will be asked to provide a signed acknowledgment of receipt of this notice. It is our intention to advise you of the permissible uses and disclosures. The services will not be conditioned upon your signed acknowledgment.

NOTICE OF PRIVACY PRACTICES

This Notice describes the types of uses and disclosures regarding your Protected Health Information (hereafter referred to as "PHI"); it explains how, when and why we use and disclose PHI about you; it notifies you that we may use and disclose your PHI as described in this Notice.

WHO WILL FOLLOW THIS NOTICE

This Notice describes the information privacy practices followed by our employees, staff and other office personnel. The practices described in this notice will also be followed by health care providers you consult with by telephone (when your regular health care provider from our office is not available) who may provide "on-call coverage" for your health care provider.

OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION

We are required to protect the privacy of your health information that can identify you. This information is called "PHI." We understand that mental health and other health information about you is personal. We are committed to protecting PHI about you. We must protect PHI information that we created or received about your past, present, or future health condition; the services, care and treatment provided to you; or payment for your health care.

HOW MAY WE USE AND DISCLOSE PHI ABOUT YOU

For Treatment: We may use and disclose PHI about you to provide you with medical and mental health care and other related services. We may use and disclose PHI about you to coordinate or manage your medical and mental health care and other related services.
– We may disclose PHI about you to doctors, nurses, technicians, or other personnel who are involved with the delivery of services provided to you.
– We may communicate with other medical, mental and other health care providers regarding your treatment, the coordination, and management of your health care with others.
– Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.

For Health Care Operations: We may use and disclose your PHI in order to run the office and make sure that we provide quality care and reduce health care costs. Examples of the way we may use or disclose your PHI for "health care operations" include the following:
– To review and improve the quality, efficiency, treatment, services and cost of care provided to you and to evaluate the performance of staff providing services to you.
– To review and evaluate the skills, qualifications, and performance of health care providers taking care of you.

For Payment: We may use and disclose your PHI to others such as your insurance company and third party payers for purposes of receiving payment for the services rendered. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also share portions of your medical information with the following:
– Billing departments;
– Collection departments or agencies;
– Insurance companies, health plans and their agents which provide you coverage;
– Consumer reporting agencies (e.g., credit bureaus).

Appointment Reminders: We may use and disclose your PHI to contact you regarding the scheduling of an appointment, to remind you of an appointment, and to send written notification of a scheduled appointment for treatment.

Treatment Alternatives: We may use your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health Related Benefits and Services: We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you. For example, if you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you.

To Avert Serious Threat To Health Or Safety: We may use and disclose your PHI consistent with applicable state and federal laws and standards of ethical conduct, if we in good faith believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or that of a person or the public; if the disclosure is made to a person or person(s) reasonably able to prevent or lessen the threat, including the target of the threat or is necessary for law enforcement authorities to identify or apprehend an individual. Additionally, we may use and disclose your PHI when the disclosure relates to victims of abuse, neglect or domestic violence.

Research: Under certain circumstances, we may use and disclose your PHI for research purposes, but only under specific criteria. You have the right to request information about these criteria and may obtain a copy of the policy by contacting the Privacy Officer in writing.

Worker's Compensation: We may release your PHI for worker's compensation or similar programs as authorized by state worker's compensations laws and programs.

Public Health Activities: We may use and disclose your PHI for public health reasons in order to prevent or control disease, injury or disability, report births, deaths, suspected abuse or neglect, non accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities: We may use and disclose your PHI to a state or federal health oversight agency which is authorized by law to oversee our operations. These activities include audits, investigations, inspections, and licensure. These activities are required by government programs to monitor the health care system, government programs and compliance with applicable laws, including civil rights law.

Judicial Administrative Proceedings, Lawsuits And Disputes: If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. Prior to this disclosure, we must make a good faith effort to inform you about the request or to obtain an order protecting the information requested and to follow applicable state laws.

As Required By Law: We will disclose your PHI when required to do so by federal, state or local law or other judicial or administrative proceedings.

Specialized Government Functions: If you are a member of the armed forces, we may disclose your PHI as required by military command authorities. We may use and disclose your PHI to authorized federal, foreign and other national security officials when the use and disclosure is for activities deemed necessary to assure the proper execution of the military mission or for other specialized government functions.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

EXAMPLES OF OTHER PERMISSIBLE OR REQUIRED DISCLOSURES OF HEALTH INFORMATION ABOUT YOU WITHOUT YOUR AUTHORIZATION:

Business Associates: Some activities are provided on our behalf through contracts with business associates. Examples of when we may use a business associate include coding and claims submission performed by a third party billing company, consulting and quality assurance activities provided by an outside consultant, billing and coding audits performed by an outside auditor, and other legal and consulting services provided in response to billing and reimbursement issues which may arise from time to time. When we enter into contracts to obtain these services, we may need to disclose your PHI to our business associate so that the associate may perform the job which we have requested. To protect PHI, however, we require our business associate to appropriately safeguard your information.

Communication with family members: Health professionals, including those employed by or under contract may disclose to a family member, other relative, close personal friend or any other person you identify, health information relative to that person's involvement in your care or payment related to your care, unless you object to the disclosure.

Federal law allows for the release of your PHI to appropriate health oversight agencies, public health authorities or attorneys, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public. Any use or disclosure of your PHI that is not described in this notice will be made only with your written authorization.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION:

Right to Inspect and Copy: You have the right to inspect and copy all or any part of your medical or health record, as provided by federal regulations. You may request and receive an electronic copy of your protected health information, or "PHI" if we maintain your PHI in an electronic health record. To inspect and copy your PHI, you must submit your request in writing to our Administrator at the address listed on the first page of this notice. The right of access to inspect and copy must be subject to and consistent with applicable laws as set forth in the Florida Statute. In addition to the Florida law requirements, the following exceptions apply: psychotherapy notes; information compiled in reasonable anticipation of or for use in a civil, criminal or administrative proceeding; or subject to the Clinical Laboratory Improvement Amendments of 1988. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. If you request a copy of your PHI we may charge a reasonable, cost-based fee in accordance with state law for the costs associated with fulfilling your request. We may deny your request to inspect and copy your PHI in certain limited circumstances.

Right to Amend: You have the right to request that we amend your PHI, clinical or billing record about you if you feel that health information we have about you is incorrect or incomplete. You have the right to request an amendment for as long as we keep your information. Your request for amendment must be in writing and you must provide the basis for the requested amendment. If we accept your requested amendment, in whole or in part, we will respond in a timely manner and forward a copy of the amendments to the relevant person(s), if necessary. If we deny your request for an amendment, we will respond to you in writing, stating the basis of the denial of your request.

Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your PHI we have made, except for disclosures made for the purpose of treatment, payment, health care operations and certain other purposes if such disclosures were made through a paper record that is not electronic, as set forth in federal regulations. If you request an accounting of disclosures of your PHI, the accounting may include disclosures made for the purpose of treatment, payment and health care operations that are made through an electronic health record. To request an accounting of disclosures, you must submit your request in writing to our Administrator at the address listed on the first page of this notice. We will, to the extent possible, mail you a list of disclosures in paper form within 60 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; such date will not be later than a total of 90 days from the date you made the request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the use and disclosure of your PHI. You also have the right to request a restriction or limitation on the disclosure of your PHI to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request for restrictions, except if you pay for a service entirely out-of-pocket. If you pay for a service entirely out-of-pocket, you may request that information regarding the service be withheld and not provided to a third party payor for purposes of payment or health care operations. We are obligated by law to abide by such restrictions. To request a restriction on the use and disclosure of your PHI, you must make your request in writing to our Administrator at the address listed on the first page of this notice. In your request, you must tell us what information you want to limit and to whom you want the limitations to apply. We will notify you of our decision regarding the requested restriction. If we do agree to your requested restriction, we will comply with your request unless the information is needed to provide you emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures as previously addressed in this Notice.

Right to Revoke Authorization: If you execute any authorization(s) for the use and disclosure of your PHI, you have the right to revoke such authorization(s), except to the extent that action has already been taken in reliance on such authorization.

Right To Receive Confidential PHI: It is our practice to contact clients at the home number and address provided to us by the client. This contact information is documented in the client records. You have the right to request that we contact you in a different manner. This request is conditioned upon two requirements 1) you must provide us with the alternative phone and address or other method of contact 2) when appropriate, information as to how the method of payment, if any, will be handled. We must accommodate reasonable requests if you clearly state that the disclosure of all or part of the information that you are requesting could endanger you.

Right To A Copy Of This Notice: You have the right to receive a paper copy of this Notice on the date you first receive service from us. In an emergency situation, we will provide the Notice to you as soon as possible. We reserve the right to change the terms of this notice and will inform you of any changes. You then have the right to object or withdraw as provided in this notice.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us or with the Secretary of Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C., 20201. You will not be penalized for filing a complaint. We will not take any action against you or change our treatment of you in any way.

END OF DOCUMENT

Receipt and Acknowledgment of Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Stephanie Silberman, Ph.D.'s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Dr. Silberman at 10059 NW 1st Court, Plantation, FL, 33324 or (954) 873-6683.

Private Contract — Provider Opt-Out of Medicare

Provider Name: Stephanie Silberman, PhD
Provider Address: 10059 NW 1st Ct, Plantation, FL 33324

This private contract agreement is between Stephanie Silberman, PhD and the beneficiary noted above. The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The provider above has informed the beneficiary or his/her legal representative that they have opted-out of the Medicare Program. The current Medicare opt-out period is January 1, 2025 to December 31, 2027. The provider noted above is not excluded from participating in Medicare Part B under §§1128, 1156 or 1892 of the Act. The beneficiary or his/her legal representative has read and agree to the following terms of the private contract by signing below:

  • I, or my legal representative, accept full responsibility for payment of Dr. Silberman's charges/fees for all services furnished by this practitioner;
  • I, or my legal representative, understand that Medicare limits do not apply to what the practitioner may charge for items or services furnished by the practitioner;
  • I, or my legal representative, agree not to submit a claim to Medicare or to ask the practitioner to submit a claim to Medicare;
  • I, or my legal representative, have been informed of the current opt-out period; which is 1/1/2025 - 12/31/2027;
  • I, or my legal representative, understand that Medicare payment will not be made for any items or services furnished by the practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;
  • I, or my legal representative, enter into this contract with the knowledge that the beneficiary has the right to obtain Medicare-covered items and services from practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out;
  • I, or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;
  • I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

By submitting this form, you confirm that the information provided is accurate. Your completed intake paperwork will be emailed to Dr. Silberman's office as a PDF.