Patient Online Forms

New Patient Information

Patient’s Name (First, Middle, Last): _______________________________________________

Address: ____________________________________________________________________

City:________________________ State:________________________ Zip:______________

Email: _______________________________________________________________________

Main Contact #: __________________________ Alternate #: _________________________

Date of Birth (DOB): ––––/––––/–––– Sex (circle one): Male Female Other

Marital Status (circle one): Single Married Divorced Widowed

Occupation: __________________________________________________________________

Patient Referred By: ___________________________________________________________

Spouse’s Name: ______________________________________________________________

Spouse’s DOB: _________________________________________________________

Main Contact #: _________________________ Alternate #: _________________________

Emergency Contact: ___________________________________________________________

Relationship: _________________________________________________________________

Phone #: ____________________________________________________________________

Primary Care Physician: ________________________________________________________

Phone #: ____________________________________________________________________

Referring Physician: ___________________________________________________________

Phone #: ____________________________________________________________________

Insurance: ___________________________________________________________________

Policy/ID: ____________________________________________________________________

Name of Policy Holder: _________________________________ DOB: ––––/––––/––––

Group/Acct #: ____________________________ Employer: __________________________

Have you been seen at another mental health facility (circle one)? Yes No

What are the goals you would like to reach at our practice?

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

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PRACTICE POLICIES & INFORMED CONSENT FOR ASSESSMENT AND TREATMENT

Name: ______________________________________________________________________

DOB: ––––/––––/––––

I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

INTAKE: The first appointment, which is considered an “intake appointment,” is a time for you to discuss your concerns, background, and social/developmental history, as well as the problem from your point of view. It is also a time to discuss with the clinician a plan for therapy.

TREATMENT TERMINATION: Please be advised that ALL patients will be charged a $50.00 No Show Fee when failed to show for a scheduled appointment. This fee will be due and payable at your next appointment. If you are a no-show patient with two consecutive missed appointments, we will not schedule any further appointments and you will be discharged from the practice. If, after the intake, your nurse practitioner or therapist identifies your treatment needs are out of their scope of practice, we will refer you to an appropriate provider.

MEDICATION POLICY: You MUST BE SEEN in the office every three months for your evaluation and management of your medication. Failure to keep these appointments could prevent your medication refill. If you miss your 3-month follow-up appointment, depending on the circumstances, Nurse Practitioners may fill your prescription with enough medication until your rescheduled appointment. If you miss that appointment YOUR MEDS WILL NOT BE REFILLED UNTIL YOU ARE SEEN, ANY and ALL medication requests will be filled in 48-72 hours.

INSURANCE: Your insurance company will require that your provider includes on any billing statement of services a Procedural Code(s) called a CPT code and a Primary Diagnostic Code, or ICD Code. You may discuss the use of these codes, but all final diagnostic decisions must be left to your provider’s discretion. By submitting your insurance information and requesting that We bill your insurance company on your behalf, you are giving this practice the following “signature on file” permissions: permission to release private information necessary to process the insurance claim on your behalf, Payment in full is expected at the time of service. This includes your portion of the fee not covered by your policy, including any co-payments or co-insurance, and if applicable, meeting your required annual deductible. You will also be responsible for any portion of the balance due that is denied by the insurance company, regardless of the circumstances.

Billing Practices and Financial Agreement Form

Self-Pay Fees:

  • Initial Assessment by Nurse Practitioners – $200

  • Follow-Ups by Nurse Practitioners – $150

  • Initial Assessment by Therapists – $125 – $150

  • Follow-Ups by Therapists – $100 – $120

Acceptable forms of payment are cash, check, or debit/credit card and flexible spending cards. If your check is deposited and returned for insufficient funds, you will be charged a $35.00 Insufficient Funds Fee.

We reserve the right to temporarily suspend scheduling further appointments if an outstanding balance is not paid and/or payment arrangements are not made in advance.

ALL BALANCES OF $150.00 OR MORE WILL NEED TO BE PAID IN FULL BEFORE YOUR NEXT APPOINTMENT OR WE WOULD NEED TO RESCHEDULE UNTIL IT IS PAID.

Cancelation and Late Arrival: Since your appointments involve the reservation of time specifically for you, a minimum of 24-hour notice is required for rescheduling or canceling an appointment. If 24-hour notice is not provided, you will be charged a $50.00 missed appointment fee. If you are going to be MORE than 15 minutes late to your scheduled session, please notify us as soon as possible. If your provider is unable to accommodate the late arrival, you will need to reschedule, and this may result in a $50,00 no-show/late cancellation fee. Please note, insurance companies will not reimburse for missed sessions or sessions that are canceled late, and you will be responsible for the $50.00 no-show/late cancellation appointment fee to be paid prior to being seen at your next scheduled appointment time.

Consent for Treatment & Policies Acknowledgement

I have read The Informed Consent for Assessment and Treatment and Office Policies, and I understand and accept the policies contained therein. Having read that information, I hereby agree to assessment and treatment. I acknowledge that this consent is truly voluntary and is valid until revoked. I hereby consent for my provider to release information to the billing agent/funding source and for the billing agent/funding source to release information to your provider. I understand that I am responsible for any fee not covered by insurance and agree to pay for sessions or co-pays at the time of service. I also understand the cancellation policy and that I will be responsible for the late cancellation and/or no-show fee if I do not provide 24-hour notice. I authorize the release of any information relating to all claims and benefits submitted on my behalf or on behalf of my child or minor in my legal custody. I further acknowledge that my signature here authorizes the clinician or his/her billing specialist to submit claims for services rendered without obtaining my signature on every claim. I understand that I am responsible for paying the co-pay, coinsurance, or deductible amount at the time of service. If the claim is denied, I agree to pay for the service. I authorize payment of medical benefits for assessment or psychotherapy to the providing clinician, for services rendered. I acknowledge that I have been given the opportunity to read a copy of the Notice of Privacy Practices.

My signature indicates that I have read, understood, and been offered a copy of the document, Informed Consent for Assessment and Treatment and Office Policy, and any other document(s) mentioned above. I acknowledge that I agree with the information presented within, and by initialing the statements above, agree to each item as indicated

___________________________ ___________________________

Patient Name (Print) Patient Signature

___________________________ ___________________________

If signed by other than patient, Date

indicate relationship

Therapist Intake Questions

Name: ______________________________________________________________________

DOB: ––––/––––/––––

Why are you seeking help now? What is happening or is different? What stressors do you have? What do you hope will be different by seeking help?

Please give more details about the issue you named above: When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?

Have you ever experienced similar or other mental health symptoms before? If so, what was your experience like? When did it happen? Did you get help?

Has anyone in your family ever experienced mental health or substance use issues? If so, who was it? Did they seek help or get a diagnosis? What was it like for them? What was it like for you?

Do you have any current or prior medical issues? If so, what was/is it? Have you seen a doctor or other healthcare professional for it? What recommendations or treatments did you have? Is there any family history of disease?

Are you currently prescribed any medications? If so, please list the name, dosage, how often you take it, and the prescriber for each medication.

Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed? If so, which? When did you start, how often did/do you use, and how long did this occur? Please list each substance separately.

Who is in your family? What is your relationship with them like? Please list all individuals you consider to be a part of your family. For those who are not part of your family of origin (such as significant others), please include the duration of your relationship.

What social activities and relationships do you engage in? What important social relationships do you have? Do you belong to any social clubs or organizations? How do you like to spend your leisure time?

What spiritual practices and cultural influences are important to you? Do you belong to a religious, faith, or spiritual community? What other cultural groups do you identify with? How do you celebrate culture and spirituality in your life?

What was life like as you were growing up, both at home and in school? Did you meet developmental milestones on time or experience any delays? What were your friends like when you were younger? What was school like for you?

What significant educational and work/volunteer experiences have you had? What is the highest level of education you have completed? Are you currently employed? If so, where and for how long? What other work and educational experiences have you had (such as a stay-at-home parent or semester abroad)? Are you satisfied with your current employment and education?

Do you have any current or prior legal issues? Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matter? If so, please describe them.

What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful? What coping skills have been working for you so far? What is important to know that will help make our time more effective for you?

What else is important to know about you?

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents, or children to call and request the result of tests, procedures, and financial information. Under the requirements for H.I.P.A.A., we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical and or mental health information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

FNM

I authorize Advanced Practice Mental Health and Wellness to speak on my behalf and in regards to my medical and mental healthcare to the following individuals:

  1. _______________________________ Relation to Patient:_______________________

  2. _______________________________ Relation to Patient:_______________________

  3. _______________________________ Relation to Patient:_______________________

  4. _______________________________ Relation to Patient:_______________________

Authorization Regarding Messages

___ I authorize you to leave a detailed message on my home or cell number regarding my appointments.

___________________________ ___________________________

Patient Name (Print) Patient Signature

___________________________ ___________________________

Patient DOB Date

Please Check Off Any Current or Past Medications

Name: ______________________________________________________________________

DOB: ––––/––––/––––

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

PHI identifies you and health care provided to you or payment for your health care, or information about your past, present, or future medical condition. This Notice explains our legal duties and privacy practices concerning your PHI. We must follow the terms of this Notice and use/disclose PHI only as described in this Notice. We may change the terms of this Notice and make the new Notice effective for all DMH PHI. You may get a copy by contacting the office where you were or are receiving services.

Unless permitted in this Notice, we cannot use/share your PHI unless you sign an Authorization. You may cancel an Authorization in writing and we will no longer use/share PHI for that purpose. However, we cannot take back any use/release made with your Authorization and we must keep records of your Treatment. Uses/Disclosures of Your PHI for Which You May Request a Restriction (see “Privacy Rights” below).

Treatment: We may use/share your PHI needed for your DMH and other providers’ Treatment or care (your diagnosis, medications, treatment plan, etc.), including PHI needed for case management, consultation, and referral with/to other Treatment or care providers.

Payment: We may use/share PHI (Treatment dates or types) to bill/be paid for Treatment (insurance/Medicaid/Medicare or other payers). We may also share PHI with payers before we provide Treatment to get their approval or find out if the type of treatment is covered.

Operations: We may use/share PHI for our Operations, for example, sharing PHI between our offices to determine what services you need. We may sometimes share PHI for Operations of agencies and organizations with .health care accrediting or licensing authority.

General Notification: We may share with your caregiver, family, close friend, or a person with whom you identify: your name, the location where you are receiving treatment, and your general condition.

Persons Involved in Treatment/Payment: We may share PHI with your caregiver, family, close friend, or other person involved in your Treatment or Payment as needed for your Treatment or Payment.

Keep You Informed: We may phone and/or mail you reminders for appointments, need for our services, Treatment information, health care benefits or related services, and satisfaction surveys.

Uses/Disclosures of Your PHI Without a Right to Request a Restriction:

  • Public Health and Health Oversight

  • Court Ordered Treatment/Evaluation or Emergency Admission

  • By Law

Privacy Rights Right to a Paper Copy of this Notice: You have the right to request a paper copy of this Notice at any time by contacting the Privacy Officer.

Right to Request Restrictions: You have the right to request in writing restrictions on our use/sharing of your PHI for treatment, payment, or operations. You may request that PHI not be shared with others (such as your spouse). Although we are not required to agree to a request, we will accommodate reasonable requests if practical and if they will not compromise the treatment.

Right to Request Confidential Communications/Notification: You have the right to request in writing how you want us to communicate with you by indicating how/where you are to be contacted, e.g., only at work or by regular mail. We will accommodate reasonable requests if practical and if it will not compromise your Treatment.

Right to Inspect and Copy: You have the right to ask in writing to see and receive a copy (including an electronic copy if the PHI is maintained in electronic form) with applicable charges apply for copying, retrieval, postage, etc. of your PHI in a Designated Record Set. We will usually provide copies within 30 days of request. If you agree, instead of providing copies, we may provide a written summary of the PHI requested (charging you the agreed-upon preparation cost). If we deny a request, we will do so in writing giving our reasons and you may have the right to have that decision reviewed.

Right to Request Amendment: If you believe your PHI is incorrect or incomplete, you may ask in writing that we amend it, stating why the PHI is inaccurate or incomplete. Normally we will respond in writing within 60 days of your request. We may deny your request if the PHI was not created by DMH, is not part of the Designated Record Set you may see and copy, or if it is accurate and complete. If so, we will let you know in writing giving our reasons. You may file a written disagreement and we may provide you with a written reply.

Right to an Accounting of Disclosures: Accounting does not include disclosures made: for treatment, payment, or operations; for general notification; to you or your caregiver; made by Authorization; for national security or intelligence; to correctional facilities/law enforcement holding custody; or to health oversight/law enforcement if it would impede those activities. We will normally provide an accounting within 60 days of request. The first list within a 12-month period will be free. We will charge you for any subsequent list within the 12-month period.

Right to File a Complaint: You have the right to file a written complaint with the Privacy Officer and/or HHS as described on the first page.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge receipt of notice of privacy practices, which explains my rights and the limits on ways my provider may use or disclose personal health information to provide service.

___________________________ ___________________________

Patient Name (Print) Patient Signature

___________________________ ___________________________

If signed by other than patient, Date

indicate relationship