Authorization for Release of Health Information Pursuant to HIPAA

Submit a release form to share your health information with another provider, agency, or third party.

If you need your records shared with another therapist, healthcare provider, attorney, or organization, you’ll need to complete an Authorization for Release of Health Information form.

This form allows us to release specific records only with your written consent — in accordance with HIPAA privacy regulations.

This section-by-section guide will help ensure your form is completed accurately and processed without delay.

When filling out your authorization form:

♥ Clearly specify what information you want shared (e.g., progress notes, summaries, treatment plans).

♥ Identify to whom the information should be released (name, organization, and contact details).

♥ Include dates of service or timeframes relevant to your request.

♥ Sign and date the form electronically or by hand to authorize release.

You may request access to your clinical records or a treatment summary at any time. Our Records Request Form allows you to submit your request securely and conveniently online. Whether you need documentation for personal use, coordination of care, or legal purposes, our team will ensure your request is handled promptly and in compliance with HIPAA regulations.

When completing the form, please:

♥ Specify whether you’re requesting copies of your full record or a summary.

♥ Provide clear details about who should receive the records (if applicable).

♥ Include the dates of service or timeframe you need covered.

♥ Upload a valid photo ID for verification (required for all record releases).

Once submitted, our administrative team will review your request and reach out to confirm details or clarify any information before processing.

A records reproduction fee may apply in accordance with New York State law. The cost will be provided to you before your request is completed.

🕒 Please allow 30 days for standard requests. Requests requiring full medical record may take additional time.

Access your secure client portal to manage appointments, complete forms, and send messages to your therapist.

Our client portal (powered by Ensora Health) allows you to conveniently manage your care in one place:

• View and schedule appointments

• Complete intake and consent forms

• Send secure messages to your therapist

• Review invoices and make payments

Need help logging in? Email our front office at hello@loveandlightpsychotherapy.com for assistance.

Need to share important documents with our team? Use our secure Uploads Form to send required files directly to our administrative staff.

This form ensures your sensitive information is protected while allowing us to process your registration and insurance details quickly.

You can upload:

• A photo ID (driver’s license, passport, or state ID)

• Front and back of your insurance card(s)

• Any other supporting documentation requested by our staff

All uploads are encrypted and stored securely in compliance with HIPAA and data protection standards. No documents are ever shared without your consent.

If you’re unsure which documents to upload, please reach out to hello@loveandlightpsychotherapy.com and our front office will guide you.

If you’re in crisis or need immediate help, you’re not alone — support is available 24/7.

If you or someone you know is in danger or emotional distress:

• Call or text 988 – Suicide & Crisis Lifeline (24/7)

• Call 911 – for emergencies or immediate risk

• LGBTQ+ Support: The Trevor Project – 1-866-488-7386

🖤 Love Light Mental Health Counseling Services, PLLC is not a crisis center. These resources can connect you to immediate, confidential help.

Rates

For information about our rates, please contact our office directly. We aim to provide high-quality care that is accessible and affordable. Our team is happy to discuss our fee structure with you in detail.

Insurance

We accept a variety of insurance plans to make our services as accessible as possible. Please contact our office to verify your insurance coverage and discuss any questions you may have about using your insurance for our services.

Our Network Partners

♥ Aetna - NY/NJ

♥ Cigna Evernorth Health - NY/NJ

♥ 1199 SEIU National Benefit Funds - NY

♥ Magnacare Network - NY

♥ Anthem Network- Formerly Empire Blue Cross Blue Shield - NY

♥ Blue Cross Blue Shield of Massachusetts - NY

♥ Carelon Behavioral Health - NY/NJ

♥ Optum Network - Including United Healthcare, UMR, Oxford Health Plans, UBH General, Oscar Circle Plus, Oscar Health, Oscar Small Group - NY

♥ Highmark

⚠️ Note: Coverage may vary based on license type or supervision. Contact our front office for verification.

Key Questions for your Insurance Provider

1. Are mental health and telehealth appointments covered?

2. Is there a deductible for telehealth, and has it been met?

3. How many sessions are allowed per year?

4. Is written approval from a primary care physician needed for coverage?

Remember, understanding your insurance benefits empowers you to make informed decisions about your mental health care.

We Accept OON Benefits

Coverage depends on your health insurance or employee benefit plan. Contact your provider to understand coverage for psychotherapy services, including telehealth.

For all other insurances not listed above, you may have out-of-network benefits, which means that those benefits will support the cost of our services.

Cancellations

We understand that life happens. For appointment cancellations, please inform your therapist directly and promptly to minimize fees.

If you need to cancel or reschedule, please provide at least 48 hours’ notice so we can offer your slot to another client. All cancelled sessions are subject to a fee, as this time is reserved specifically for you.

Note: Cancellation fees are payable out-of-pocket. They are not covered by your insurance plan.