Patient Information Form Trinity Wellness Center. Insurance Information

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1 Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student Marital Status (circle one): Married / Single / Divorced / Legally Separated / Widowed Employment Status: Full-time / Part-time / Self-employed / Not employed / Retired / Military Referring Provider Self-Pay patient?: Yes / No Privacy Statement Received?: Yes / No if yes, list date : / / at am/pm Mailing Address* City* State* Zip/Postal Code* Home Phone* ( ) Cell Phone/Pager ( ) Primary Care/Family Doctor Name & Number* Pharmacy Name & Phone Number* Emergency Contact * Insurance Information Visit Copay: $ Primary Insurance Secondary Insurance Tertiary Insurance Insurance Name*: Insurance Address*: City/State*: Zip*: Insurance ID*: Group/Policy #: Claims Phone: ( ) Eligibility Phone: ( ) Patient s Relationship to Insured: Insured Name (if different than patient)* SSN : - - Sex: M / F Date of Birth*: / / Phone*: ( ) Insured Address*: City/State*: Zip*:

2 PATIENT RECORD DISCLOSURE In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that communication of PHI be made by alternative means, such as sending correspondence to the individual s office instead of the individual s home. Preferred Contact Phone Number: Preferred Contact Address: Signed Date CONSENT FOR EXCHANGE OF INFORMATION I hereby authorize Trinity Wellness Center to (exchange, release, obtain) information in my client record with: I authorize Trinity Wellness Center to exchange, obtain, or release information to my insurance provider : (you must check yes if you wish for us to file with your insurance) YES NO I authorize the staff at Trinity Wellness Center to exchange information with each other for the purpose of providing my care: YES NO This data shall include reports and or summaries of treatment/psychotherapy while in your care to aid in evaluation. This consent shall be valid for: This consent is fully understood and made voluntarily on my part. I understand that I may withdraw this consent (in writing) at an time except to the extent that action based on this consent has been taken. I also understand that this consent will automatically expire one year from the date it is signed. Signed Date

3 Practice Information It is our goal to make your experience here an informed and positive one. Please review and complete the following information. If you have any questions, please feel free to discuss them with us. Thank you. Payment Information and Insurance Coverage Insurance- We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility, we do not guarantee coverage with proof of insurance. Please contact your insurance company with any questions you may have regarding your coverage. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Co-payments & Deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Delinquent accounts of 60 days or more will be charged an additional $25 fee. Cancellations and Missed Appointments. Patients are requested to give notice as soon as possible when canceling or rescheduling appointments. Appointments canceled with less than 24-hour notice or missed appointments will be charged a fee of $ Voice mail is provided for after-hours cancellations. If an appointment with a prescriber is missed and it is necessary to have medications phoned in, there will be a $25.00 charge for this service. Paperwork. Any forms not associated with reimbursement of a claim will be a $25.00 fee or more to the patient at times due prior to the completion of the forms. Patient Consent I have read and understand the payment policy and agree to abide by its guidelines: Patient (or Guardian) Signature Date

4 NOTICE OF PRIVACY PRACTICES SUMMARY This notice is a summary of how your protected health information is used and disclosed and how you can obtain access to this information. Please see the front desk to review a full copy of our Notice of Privacy Practices. Uses and Disclosures of Health Information We use health information about you for treatment, to obtain payment for treatment, for administrative purposed, and to evaluate the quality of care that you receive. We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give you health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures. We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. Your Rights Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to: request a restriction on certain uses and disclosures of your information as provided by 45 CFR obtain a paper copy of the notice of privacy practices upon request inspect and obtain a copy of your health record as provided for in 45 CFR amend your health record as provided in 45 CFR obtain an accounting of disclosures of your health information as provided in 45 CFR.528 request communications of your health information by alternative means or at alternative locations revoke your authorization to use or disclose health information except to the extent that action has already been taken Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we 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 We are required be law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. If you have questions or complaints, please contact : Trinity Wellness Center, 1907 South 17 th Street Suite 1, Wilmington, NC 28401, phone WRITTEN ACKNOWLEDGEMENT I acknowledge that I have reviewed the Notice of Privacy Practices which provides a description of information uses and disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions I request. Signature of Patient (Guardian) Date

5 Trinity Wellness Consent to Treatment I, the undersigned patient, have chosen to receive psychiatric/psychological services from R. Thomas Mathew, M.D. and/or his associates. My choice has been voluntary and I understand that I may terminate treatment at any time. If I terminate treatment I will inform Dr. Mathew in writing. I understand that Trinity Wellness Center may terminate treatment with me at any time upon thirty days written notice to the last address in our records whether or not I have acknowledged receipt of this notice. (initial) I understand that Dr. Mathew is limiting his practice to psychiatry (or the licensed area or practice in the case of a designee), and I will see my primary physician for checkups and any and all medical problems. I will hold Dr. Mathew harmless for any adverse outcomes if I do not follow any referral recommendations or see my primary physician. I consent to the release of information to my primary physician and consultants, and I understand that Dr. Mathew will share information concerning my treatment. I also consent to the release of information from my primary physician to Dr Mathew. I will sign releases of information allowing these activities. I will hold Dr. Mathew harmless for the actions of any other physician or healthcare professional including but not limited to those practicing within his offices, and I will hold any other physician or healthcare professional including but limited to those practicing within his offices, harmless for the actions of Dr. Mathew. (initial) I understand that all communications and records of information collected about me will be protected or released in accordance with state and federal laws regarding confidentiality of such records and information. I understand that state laws require Dr. Mathew to report all cases of abuse or neglect of minors or the elderly. I understand that there may be other circumstances in which the law requires disclosure of confidential information. I understand that Dr. Mathew will release medically necessary information for my treatment in an emergency situation. I will hold Dr. Mathew harmless for any further release or distribution of Protected Heath Information (PHI) by a third party and any breach of privacy associated with the electronic transmission of PHI that is otherwise authorized or legally allowed. (initial) I understand that I will have the opportunity to participate in the development of a plan for my treatment that any recommendations will be explained to me. I understand that I have the obligation to ask questions regarding any treatment recommendation(s) if I do not fully understand. I agree to hold Dr. Mathew harmless for any failure on my part to ask questions when I do not understand, including questions regarding my medication and side effects. I understand that I have the right to accept or reject any treatment recommendation at any time, including but not limited to any medication recommendation. If I chose to follow or not to follow any of Dr. Mathew's recommendations, I agree to hold Dr. Mathew harmless for any injury to me arising from my own decisions. If I am taking any medications and am having any side effect or adverse reaction whether explained to me or not and I choose to continue taking this medication without discussing this side effect or adverse reaction with Dr. Mathew, I agree to hold Dr. Mathew harmless for my decision. I agree to hold Dr. Mathew harmless for any side effects or adverse reactions to any treatments prescribed or administered under Dr. Mathew's supervision when I have consented through this or any other consent for treatment. (initial) I understand that I have the responsibility for procurement, proper care, storage, and security of the medications prescribed to me by Dr. Mathew and that if refills are not available on the current prescription it is my responsibility to make an appointment so that another prescription is given. I understand that it is my responsibility to assure that the medication is not lost, stolen, or destroyed. I understand that medications prescribed by Dr. Mathew may not be dispensed without a prescription and that it is illegal to exchange prescription medication with another person without a prescription. I will hold Dr. Mathew harmless for consequences of my acts and/or omissions regarding medications prescribed by Dr. Mathew from my failure to procure properly, care for, secure, store, or otherwise conserve said medication. (initial) I understand that my participation in the recommended treatment, including but not limited to attending all scheduled appointments, is necessary to achieve the best possible outcome. I understand that I will be billed for any missed appointments or any appointments canceled within 24 hours (weekends or holidays are not included in the count of the 24 hours). If I miss an appointment, I understand that there is no assurance that I will be worked in the same day or seen before prescribed medication is depleted. If I miss my appointment, I

6 understand that I am responsible for payment of the full appointment time whether or not Dr. Mathew is able to spend less time with me on a work in basis. If Dr. Mathew is working me in after I have missed an appointment, I understand that any patient coming to an appointment on time may be seen ahead of me. I understand that I may be asked to reschedule if I miss my appointment by coming late to an appointment. (initial) I understand that there is no assurance or guarantee that I will feel better. In fact, there are no guarantees that any medical or psychiatric illnesses will respond to treatment by any physician. I am contracting with Dr. Mathew for his services and specifically not contracting for Dr. Mathew to guarantee improvement. I understand that Dr. Mathew's practice is currently limited to outpatient treatment and that I am responsible for securing an inpatient facility and inpatient physician for treatment should this become necessary. I understand that in the event of an emergency I will be responsible for seeking emergency treatment at a local emergency room or psychiatric facility. (initial) I understand that working through problems is part of the development of good mental health. If I have any misunderstandings with Dr. Mathew I agree to work with him to resolve any differences in opinion. If there is no satisfactory resolution after this, I agree that I will submit the matter to an independent arbitrator. I agree not to enter into any contingency agreement with any attorney at law for the purpose of litigation regarding any and/or all aspects of this consent for medical services. I waive my right of confidentiality only to the extent of legal necessity for a burden of proof in such litigation in small claims court. I agree that, if any litigation is necessary regarding any aspect of my treatment by Dr. Mathew, the total legal expenses and any and all costs caused by and/or incurred from said litigation for all parties is to be paid by the party who does not prevail. (initial) I understand that Dr. Mathew is licensed to practice medicine by the North Carolina Medical Board and is Board Certified by th American Board of Psychiatry and Neurology (Psychiatry). Other designees if licenses are responsible to the particular organization regarding their professions(s). I also understand that Dr. Mathew is not Board Certified in any other medical specialty including but not limited to the American Board of Child and Adolescent Psychiatry. I understand that Dr. Mathew will practice according to the laws of the State of North Carolina and the ethical principles of the American Medical Association. (initial) I understand that the Practice Information and Consent to Treatment/Notice of Privacy Practices are the only binding documents between Dr. Mathew and me and that no other contract, implied or otherwise, will apply to the physician-patient/physician-client relationship between Dr. Mathew and me. (initial) *Dr. Mathew refers to both Dr. Mathew and his designees including but not limited to those professionals practicing in his office unless including them would not make sense for the context in which the term is used. Practice Information and Consent to Treatment/Notice of Privacy Practices Your signature(s) below indicate(s) you have read the practice information and consent to treatment/notice of privacy practices and agree to abide by the terms. It also indicates your clear understand as to; (1)you (your child's) responsibilities; (2) the state regulatory board(s) under whose authority R. Thomas Mathew, M.D. And the other professionals within his offices operate; (3) Dr. Mathew's office/financial policies and your agreement to abide by these policies; (4) the nature of the services provided; (5) and your consent for Dr. Mathew to consult about your care with other clinicians who practice in our offices. Patient/Parent/Guardian/Legal Representative Signature Date

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