Telephone 310-475-7535
10444 Santa Monica Blvd, Suite 302, Los Angeles, CA 90025


Before your appointment

Please read and fill out the following forms before your first meeting.



Stephanie R. Baron, Ph.D 10444 Santa Monica Blvd. Suite 302 Los Angeles, CA 90025


Uses and Disclosures of Your Health Information: Dr. Baron uses health information about you for treatment, to obtain payment for treatment, for administrative purposes,and to evaluate the quality of care that you receive. Continuity of care is part of treatment and your records may be shared with other health care providers and facilities to which you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. Dr. Baron may use or disclose identifiable health information about you without your authorization for routine care and for legal reasons as described in the following pages, but beyond those situations, Dr. Baron will ask for your written authorization before using or disclosing any identifiable health information about you.

Your rights: In most cases, you have the right to look at or get a copy of health information about you. These requests must be in writing and Dr. Baron will charge you reasonable retrieval and photocopy fees. You also have the right to receive a list of certain types of disclosures of your information that Dr. Baron made. If you believe that information in your record is incorrect, you have the right to request, in writing that Dr. Baron corrects the existing information.

Complaints: If you are concerned that Dr. Baron may have violated your privacy rights, or you disagree with a decision Dr. Baron made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

Our legal duty: Dr. Baron is required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice, and seek your acknowledgement of receipt of this notice. Before Dr. Baron makes a significant change in our policies, we will notify our then current patients of such change. For more information about our privacy practices, please contact the person listed below. If you have any questions or concerns, please contact Dr. Stephanie R. Baron at the above address


The following are examples of the types of uses and disclosures of your protected health information that Dr. Baron is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures,

Treatment: Dr. Baron may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. An example of treatment would be when The Shores Counseling Center consults with another health care provider, such as your family physician or another psychologist, regarding your treatment.

Payment: Your protected health information may be used, as needed, in activities related to obtaining payment for your health care services. Examples of payment are when Dr. Baron discloses your protected health information to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Healthcare Operations: Dr. Baron may use or disclose, as needed, your protected health information to support our business activities. For example. Dr. Baron may disclose your protected health information to your health insurer or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.

Business Associates: Dr. Baron may share your protected health information with third party 'business associates ' that perform various activities (e.g., billing, transcription services). Whenever an arrangement between Dr. Baron and a business associate involves the use or disclosure of your protected health information. Dr. Baron will have a written contract that contains terms that will protect the privacy of your protected health information.

Other: Dr. Baron may use certain health information in the course of providing you directly with information about treatment alternatives within Dr. Baron’s office or upcoming appointment reminders.

Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. Authorization will also be obtained before releasing your psychotherapy notes. "Psychotherapy notes" are notes made during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than your protected health information. You may revoke or modify all such authorizations of protected health information or psychotherapy notes at any time; however, the revocation or modification is not effective until it is verifiably received by Dr. Baron.

Opportunity to Object: Dr. Baron may use and disclose your protected health information in the following instances. You have the opportunity to object. If you are not present or able to object, then your provider may, using professional judgment, determine whether the disclosure is in your best interest. Emergencies: In an emergency treatment situation, your provider shall try to provide you a Notice of Privacy Practices as soon as reasonably practicable after the delivery of treatment.

Communication Barriers: Dr. Baron may use and disclose your protected health information if your provider attempts to obtain acknowledgement from you of the Notice of Privacy Practices but is unable to do so due to substantial communication barriers and the provider determines, using professional judgment that you would agree.


Without Opportunity to Object

Dr. Baron may use or disclose your protected health information in the following situations without your authorization or opportunity to object:

Child Abuse; Whenever, in the professional capacity of, Dr. Baron has knowledge of or observes or reasonably suspects that a child known to Dr. Baron has been the victim of child abuse or neglect, Dr. Baron will immediately report such to a police department or sheriffs department, county probation department, or county welfare department. Also, if Dr. Baron has knowledge of or reasonably suspects that mental suffering has been inflicted upon a child or that his or her emotional well-being is endangered in any other way, Dr. Baron will report such to the above agencies. Adult and Domestic Abuse: If in the professional capacity of Dr. Baron, Dr. Baron has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if Dr. Baron is told by an elder or dependent adult that he or she has experienced any of these abuses and if Dr. Baron reasonably suspects such, Dr. Baron will report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency. Dr. Baron does not have to report such an incident if Dr. Baron has been told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, abduction, isolation, financial abuse or neglect and Dr. Baron is not aware of any independent evidence that corroborates the statement that the abuse has occurred; or the elder or dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservator ship because of a mental illness or dementia; or in the exercise of clinical judgment, Dr. Baron reasonably believes that the abuse did not occur. Health Oversight: If a complaint is filed against Dr. Baron with the California Board of Psychology, the Board has the authority to subpoena confidential mental health information relevant to that complaint. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that Dr. Baron has provided you, Dr. Baron must not release your information without I ) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena to produce records where the party seeking your records provides Dr. Baron with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified Dr. Baron that you are bringing a motion in the court to block or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. Dr. Baron will inform you in advance if this is the case. Serious Threat to Health or Safety: If you communicate to Dr. Baron a serious threat of physical violence against an identifiable victim, Dr. Baron must make reasonable efforts to communicate that information to the potential victim and the police. If Dr. Baron has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, Dr. Baron may release relevant information as necessary to prevent the threatened danger. Worker's Compensation: If you file a worker's compensation claim. Dr. Baron must furnish a report to your employer, incorporating Dr. Baron's findings about your injury and treatment, within five working days from the date of the your initial examination, and at subsequent intervals as may be required by the administrative director of the Worker's Compensation Commission in order to determine your eligibility for worker's compensation. In general, Dr. Baron may use or disclose your protected health information as required by law and limited to the relevant requirements of the law.


The following is a statement of y oar rights with respect to your protected health Information and a brief description of how you may exercise these rights.

You have the right to request to inspect and obtain a copy of your protected health information. All requests must be in writing and reasonable retrieval time and fees, along with reasonable copying fees will apply. Dr. Baron may refuse to provide access to certain psychotherapy notes or information for a civil or criminal proceeding. You have the right to request a restriction of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for treatment, payment or healthcare operations. You may also request that information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. Dr. Baron is not required to agree to a restriction that you may request, but if Dr. Baron does agree, then Dr. Baron must behave accordingly.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. Dr. Baron will accommodate reasonable requests. Dr. Baron may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Dr. Baron will not request an explanation from you as to the basis for the request.

You may have the right to have your provider amend your protected health information. You may request in writing an amendment of protected health information about you. If Dr. Baron denies your request for amendment, you have the right to file a statement of disagreement with us, and your medical record will note the disputed information. You have the right to receive an accounting of certain disclosures Dr. Baron may have made. This right applies to disclosures for purposes other than treatment, payment or healthcare operations. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations. Effective Date: The effective date for the above Privacy Practices is April 14, 200

Dr. Stephanie R. Baron 1
0444 Santa Monica Blvd S
uite # 401 Los Angeles, CA 90025
310 475-7535

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All information between therapist and patient is held strictly confidential unless:
1. The patient authorizes release of information with his/her signature.
2. The patient presents a physical danger to self.
3. The patient presents a physical danger to others.
4. Child/elder abuse/neglect is suspected.
In the latter two cases, I am required by law to inform potential victims and legal
authorities so that protective measures can be taken.

Upon verification of health plan,insurance coverage and policy limits, your insurance
carrier will be billed for you and your provider will be paid directly by the carrier. The
patient/guardian will be responsible for any applicable deductibles and co-payments. If
you are not eligible at the time services are rendered,you are responsible for payment.

A scheduled appointment means that time is reserved only for you. If an appointment is
missed or canceled with less than 24 hours notice, the responsible party will be billed
according to the scheduled fee or according to the rules of the patient's health plan.

I understand that I have a right to request reconsideration in the case that outpatient care
is not authorized. I understand that the request for appeal can be made through my
Provider and that I risk nothing in exercising that right.
I also understand that I have a right to submit a complaint/grievance and risk nothing to
exercise that right. I understand that to submit a complaint or grievance, I may contact the
Customer Service department of my Health Plan.

I further authorize and request that Dr. Stephanie R. Baron, Ph.D. carry out psychological
examinations, treatments and/or diagnostic procedures that now or during the course of
my care as a patient are advisable. I understand that the purpose of these procedures will
be explained to me upon my request and Subject to my agreement. I also understand that
while the course of therapy is designed to be helpful,it may, at times, be difficult and

Stephanie R. Baron, Ph.D.
Lic. #PSY 11972
10444 Santa Monica Blvd., Suite 302, Los Angeles, CA 90025

By clicking on the form below, I authorize the release of information for claims, certification,case management,quality
improvement, and other purposed related to benefits of my Health Plan. I understand and
agree to all of the above information.

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Please fill out every field as requested.

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