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 will be charged a missed appointment fee of $75. This fee will be 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 bank for non-payment, I agree to replace the check and pay a processing fee of $35. If the account is forwarded to collections, I as the responsible party may be responsible for all the collection costs and attorney fees.