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A · Assignment of Benefits & Records Release

I hereby authorize direct payment to BCB Liberty Health Care of any medical benefits payable to me for services provided. I understand it is my responsibility to obtain any required referral authorization prior to my appointment. I am responsible for any co-payment, deductible, or patient portion on the day of service. If my account becomes delinquent, I will be held responsible for reasonable attorney's fees, court costs, and collection costs.

I hereby authorize BCB Liberty Health Care to release my records to my insurance company and/or primary care physician for the purpose of processing my insurance claims. This authorization shall remain in effect as long as charges are being submitted for insurance claim processing or as dictated by the payer.

B · Notice of Privacy Practices (HIPAA)

BCB Liberty Health Care is required by law to maintain the privacy of your Protected Health Information (PHI).

B1 — Our Commitment: BCB Liberty Health Care safeguards all health information, including demographic data and records from other providers. We will notify you of any unauthorized access, use, or disclosure of your unsecured PHI.

B2 — Uses Requiring Written Authorization: Written authorization is required before disclosing PHI outside of treatment, payment, or healthcare operations. You may revoke authorization in writing at any time. We cannot retract disclosures already made.

B3 — Verbal Authorization Required For: Changes to personal information such as name, home address, and insurance information.

B4 — Disclosures NOT Requiring Your Consent:

• Treatment coordination and referrals to other providers
• Billing, payment, and insurance reimbursement activities
• Legal guardian, conservator, or healthcare agent of incapacitated patients
• Military command authorities (if applicable)
• Federal, state, or local law requirements
• Public health reporting (infectious diseases)
• Reporting abuse, neglect, or domestic violence
• Situations where you have shown signs of hurting yourself or others
• Appointment reminders and information about treatment alternatives

B5 — Your Rights:

• Examine your health record within 5 working days of written request
• Receive a copy within 15 days of written request (fee may apply)
• Request corrections to your medical record
• Withdraw authorization in writing at any time (future disclosures only)

B6 — Acknowledgment of Receipt: With my signature below, I acknowledge that I have received and reviewed the BCB Liberty Health Care Notice of Privacy Practices.

C · Telepsychiatry Informed Consent

BCB Liberty Health Care uses HIPAA-approved secured system CareCloud for all telepsychiatry sessions.

C1 — What is Telepsychiatry? Telepsychiatry allows patients to access psychiatric care using audio-video interfaces. All systems incorporate network and software security protocols to protect confidentiality and data integrity.

C2 — Expected Benefits:

• Improved access to psychiatric care — receive treatment from home or office
• More efficient psychiatric evaluation and ongoing management

C3 — Possible Risks:

• Transmitted information may be insufficient for appropriate medical decision-making (e.g., poor image resolution)
• Delays in evaluation could occur due to equipment deficiencies or failures
• In rare cases, security protocols could fail, causing a breach of privacy of personal medical information
• Lack of access to complete medical records may result in adverse drug interactions or other errors

C4 — Patient Rights — By Signing I Understand That:

1. Privacy laws protecting medical information also apply to telepsychiatry. No identifying information will be disclosed without my consent.
2. I may withhold or withdraw consent to telepsychiatry at any time, without affecting my right to future care or treatment.
3. I have the right to inspect all information obtained in telepsychiatry and may receive copies for a reasonable fee.
4. Alternative methods of psychiatric care may be available to me and I may choose them at any time.
5. It is my duty to inform my psychiatrist of any other healthcare providers involved in my care.
6. No results from telepsychiatry can be guaranteed or assured.

C5 — My Responsibilities:

1. I will NOT record any telepsychiatry sessions without the prior written consent of NP Bonu and associates.
2. I will inform NP Bonu if any other person can hear or see any part of our session before it begins.
3. I MUST be a resident of DC and physically in DC when receiving telepsychiatry services from BCB Liberty Health Care.
4. My initial consultation will be conducted via telepsychiatry.
5. My health insurance may or may not cover this service; I accept financial responsibility for the service.

C6 — Authorization: I hereby authorize BCB Liberty Health Care to use telepsychiatry in the course of my diagnosis and treatment.