This agreement puts in writing our mutual understanding regarding my taking what is called "assignment" from your insurance company. Assignment is explained under the Insurance tab of this web-site, as well as by reading the agreement itself.
When I need permission from you to speak to someone involved in your or your child's treatment (e.g., a relative, psychiatrist, other psychologist or psychotherapist, teacher, etc.), I will ask you to review and sign this form so that we have a clear mutual understanding about what will be disclosed. Often, you will also need to sign the equivalent form with the other party.
This agreement allows me to work with patients who are on Medicare, and yet opt out of Medicare's plan. It also enables Medicare patients to use their secondary insurance, if any, under the circumstances of my opting out. I am happy to explain this agreement in person or by phone.