I acknowledge that I have requested evaluation and/or ongoing treatment from Dr. Roobal Sekhon, DO at California Center for Behavioral Health. I understand that this treatment is voluntary and that I may discontinue at any time.
Missed Appointments
If I miss a scheduled appointment without at least 1 business day (24 hours) notice, I may be subject to a missed appointment fee of $75. If charged, this fee is my personal responsibility and is not covered by my insurance carrier.
Release of Information
I authorize the release of information regarding my care, including my mental health records, to my health plan or insurance carrier for the payment of claims, certifications/case management decisions, treatment authorizations, quality improvement activities and other purposes related to the administration of benefits for my health plan.
Responsibility of Payments
I understand and agree that I am responsible for any fees that I incur for services rendered by California Center for Behavioral Health regardless of insurance coverage. I understand that fees and copayments are due and payable at the time of my visit. If my check is returned by the bank for non-payment, I agree to replace the check and pay a processing fee of $25 for the first returned check and $35 for each returned check after that. If the account is forwarded to collections, I as the responsible party may be responsible for all the collection costs and attorney fees.
A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.
Open Payments Database Notice
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
Notice to Consumers
Osteopathic physicians and surgeons (D.O.) are licensed and regulated by the Osteopathic Medical Board of California, (916) 928-8390, www.ombc.ca.gov. To check the status of your physician and surgeon D.O. license, visit https://search.dca.ca.gov/. To file a complaint against the physician and surgeon D.O., use the online complaint form at www.ombc.ca.gov or email osteopathic@dca.ca.gov.
I understand that Dr. Roobal Sekhon, D.O., is licensed and regulated by the Osteopathic Medical Board of California, and I have received the Open Payments database notice above.