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1 PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt. reminders? Home Phone Cell Phone Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip Occupation Business Phone RESPONSIBLE PARTY INFORMATION All of the following information MUST be completed Who is responsible for this account? (THIS WILL NOT BE THE CHILD) Last First Middle Address City State Zip Primary Phone Cell Phone SS# Birth Date Employer Name and Phone # Do you have medical insurance? Yes No Name of Patient s PRIMARY Insurance: Policy ID # Group # Member ID# Policy Holder s Name Last First Middle Initial Holder s Address City State Zip Holder s Date of Birth Male Female SS# Holder s Occupation: Business Phone: Relationship to PATIENT Name of SECONDARY Insurance: Policy ID # Group # Member ID# Policy Holder s Name Last First Middle Initial ALL ITEMS BELOW MUST BE FILLED OUT THIS NUMBER CANNOT BE YOURS OR YOUR CELL IT MUST BE A CLOSE FRIEND OR FAMILY MEMBER. Emergency Contact Phone Number: Address of ER Contact (if different from above) (Approval is given to contact the above by listing their name) What is the relationship to the patient? How did you learn of our practice? Who may we thank for referring you? Was your appointment made in a timely fashion after your first phone call to us? Yes No 1

2 Restoration Counseling / PSET PATIENT NAME: PATIENT NO. Please read each sentence carefully. IF YOU DISAGREE WITH ANY OR ALL OF THE STATEMENT, PLEASE INITIAL IN THE SPACE NEXT TO THE CORRESPONDING STATEMENT, and notify a staff member immediately as we will NOT be able to treat you or your child if you DISAGREE with any of the statements below. Otherwise if you wish to be treated by us sign the form below. Thank you. PERMISSION TO TREAT CHILD: I give permission for Restoration Counseling / PSET to treat my child. I UNDERSTAND MY INSURANCE will be billed for this service and that I may incur a co-pay. I also understand that I am responsible for all financial obligations denied or not covered by insurance. CONTACT MY PCP: I give permission for Restoration Counseling Services / PSET to contact my PCP or my child s PCP, whatever the case may be. Consent form for a Urine / Saliva/Hair Drug Screen I, give Restoration Counseling/ PSET permission to obtain a urine specimen, saliva or hair specimen to test for any drugs and / or alcohol. I have taken medication that my physician has not prescribed. Yes Yes List medications taken over the last 3 days. (Include over the counter medication) No No You will be charged $25.00 for each drug screen. Your insurance will not be billed. You are expected to pay for drug screens at the time of service. If you are in the Intensive Outpatient Program, all drug screens must be paid for prior to successfully exiting the program. RESTORATION COUNSELING / PSET Notice of NO-Show Policy Due to high volume of patient need, appointment times are very much in demand. If you have an appointment, it must be kept. If you do not call and cancel the appointment at least 24 hours before the scheduled appointment, you or your legal guardian will be charged a No-Show fee. The No-Show fee is $ and must be collected BEFORE your next appointment can be scheduled. We regret having to take this action, but there have been too many occasions when appointments were not cancelled at least 24 hours prior to the scheduled time, thereby leaving insufficient time to contact an individual in need of an appointment to fill that slot. Please be considerate of others. The next time it could be you or someone you love in need of that appointment. Thank you for your help in this matter. 2

3 Personal Health Information Patient Name: DOB: Agencies and/or providers given authorized privilege for communication include: Probation Officer (name and phone number) Judge (name and county) Attorney Case Manager Primary Care Doctor (name and phone #) Parent or Guardian Other Doctors (Such as past mental health providers, agencies, or Specialist, OBGYN) Do you go to Hiwassee Mental Health Care/ Rhea Mental Health/Joe Johnson Mental Health Center? YES or NO School If your child goes to McMinn County High School would you like RCS to come there and see your child? Yes No 3

4 AUTHORIZATION FOR THE RELEASE OF PSYCHIATRIC PERSONAL HEALTH INFORMATION (PHI) Patient s Name Social Security # Date of Birth I give permission for Restoration Counseling LLC / PSET LLC to receive and/or disclose my psychiatric, private health information, PHI please note that psychotherapy notes are not considered part of the medical record and will not be included in this authorization. This authorization will remain in effect for one year or until the patient or his/her authorized representative revokes it in writing. Your information will be transmitted may communicated in different formats- , regular mail, phone or fax. This authorization may include the following, but not necessarily all of the information listed below: 1. Medication prescription recommendations and monitoring 2. Frequency and modality of treatment 3. Treatment plan 4. Symptoms, prognosis and progress to date 5. Diagnosis 6. Functional status 7. Results of clinical tests This information will be used to formulate, administer and coordinate treatment with my other providers including my Primary Care Physician (PCP). Agencies and/or providers given authorized privilege for communication include: List one provider per page Provider Address Phone # Patient Signature: Parent / Guardian s Signature: Relationship to Patient: This release of information will remain in effect for one year from the date of signature. AUTHORIZATION FOR THE RELEASE OF PSYCHIATRIC PERSONAL HEALTH INFORMATION (PHI) Patient s Name Social Security # Date of Birth I give permission for Restoration Counseling LLC / PSET LLC to receive and/or disclose my psychiatric, private health information, PHI please note that psychotherapy notes are not considered part of the medical record and will not be included in this authorization. This authorization will remain in effect for one year or until the patient or his/her authorized representative revokes it in writing. Your information will be transmitted may communicated in different formats- , regular mail, phone or fax. This authorization may include the following, but not necessarily all of the information listed below: 8. Medication prescription recommendations and monitoring 9. Frequency and modality of treatment 10. Treatment plan 11. Symptoms, prognosis and progress to date 12. Diagnosis 13. Functional status 14. Results of clinical tests This information will be used to formulate, administer and coordinate treatment with my other providers including my Primary Care Physician (PCP). Agencies and/or providers given authorized privilege for communication include: List one provider per page Provider Address Phone # Patient Signature: Parent / Guardian s Signature: Relationship to Patient: This release of information will remain in effect for one year from the date of signature. 4

5 AUTHORIZATION FOR THE USE AND DISCLOSURE OF PHI (Private Healthcare Information) CONSENT FORM By signing this document I give consent for my PHI to be used for specific purposes that are outlined in the NOTICE OF PRIVACY PRACTICES that has been given to me. I understand that under the terms of this consent I can ask Restoration Counseling / PSET to restrict how my personal health information is used or disclosed to carry out treatment, payment or health care operations. I understand that I have the right to cancel any consent in writing at any time. If I do cancel the consent, I understand that Restoration Counseling / PSET may have already used or disclosed information about me and canceling this consent would not effect the information already used or disclosed. I may cancel this consent at any time by doing one of the following: 1. Signing and dating a form that Restoration Counseling / PSET will give me upon request. This form is called: Revocation of Consent for Use and Disclosure of Health Care Information. Or, 2. Writing, signing and dating a notarized letter to Restoration Counseling / PSET in care of the Privacy Officer, (Practice Administrator). The letter must say that patient wants to revoke consent to authorize the use and disclosure of the patient s health care information for treatment, payment and health care operations. 3. I understand that I may revoke this consent at any time, but if I do so I will become financially responsible for costs incurred by treatment. Furthermore, the negotiated fees that are used with my insurance will not apply and I will be charged the full amount for services rendered, and / or I could be discharged from the practice. Name: 5

6 RESTORATION COUNSELING / PSET BRENDA HARTGROVE, LCSW NOTIFICATION OF RECEIPT OF IMPORTANT DOCUMENTS/INFORMATION This form indicates patient acknowledgement of receipt of a copy of the notice of privacy rules regarding the therapist and psychiatrist s use and/or disclosure of health care information and treatment. I understand my health information is private and confidential I understand that Restoration Counseling / PSET work very hard to protect my privacy and preserve the confidentiality of my personal health information. I understand that confidentiality does not pertain to life threatening situations, or abuse that must be reported. I understand that in certain circumstances records may be secured by a court order. Restoration Counseling / PSET have given me a detailed document called the NOTICE OF PRIVACY PRACTICES. This document outlines specific ways in which my private health information can be used, for example routine situations such as billing, treatment, communicating with you and other providers with your permission. Your information (with your permission can be communicated with other providers via telephone, fax, or US mail). Restoration Counseling / PSET may update this NOTICE OF PRIVACY PRACTICES and if that occurs, you will be provided with the most current copy. Would you like for anyone to be able to check on your appointment times, make appointments for you or be told if you were here for your appointment? If so, you will need to tell them your privacy number assigned at the time you turn in your paper work. Tell them, to give the receptionist your privacy number and they will be given your appointment time and date or be able to change your appointment for you. Yes No If so, a privacy number will be assigned. Please inform office manager when returning completed documents to receive assigned number. Your privacy number is:. There will be a 25% charge on all accounts turned to collections. All children under the age of 21 are eligible to receive yearly health screenings free of charge. You are also eligible to receive free transportation to these appointments. Our office provides you with information on how to access these benefits. I have been given information on the transportation and health screenings by this office. Yes No IF YOU ARE 16 YEARS OLD OR OLDER do you have a Mental Health Directive? I have received a copy of PATIENT RIGHTS along with my IOP intake packet. Yes No Yes No There are monthly fire drills at this facility. This is done in accordance with the state and local fire and safety codes. Should a fire drill occur while you are in the building do not panic. Your counselor or the ancillary staff (secretary or administration staff) is trained in what to do. They will give you clear instructions. We will meet in the bottom EAST CORNER (closest to the hospital ER but not in the road) of the parking lot and remain there until safety vehicles arrive and ALL patients and staff are accounted for. We have working fire extinguishers and fire alarms. The fire alarms will be tested in the drill and you may be asked to exit. DO NOT PANIC it is most likely a DRILL, but we have to practice so that we can keep you safe for the real thing! Thank you for your understanding and patience. If you have questions, please ask one of our staff. PATIENT S Name PATIENT S Signature Date PARENT S Name PARENT S Signature Date 6

7 PRIVACY POLICY THIS IS YOUR COPY TO KEEP THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INFORMATION. PLEASE REVIEW IT CAREFULLY. In December 2000, the Federal Government finalized Standards for privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164) The Standards are complex, and there is no clear language or information, which has been developed for professionals or for health care consumers to help you understand your privacy rights. I have done my best to understand the Standards and to inform you with this notice of your rights, limits to privacy, and my obligations. While these are government regulations, in some cases the ethical principles for Social Workers and Psychiatrists and /or state (Tennessee) regulations regarding confidentiality and privileged communication may be more stringent than regulations outlined in the Health Insurance Portability and Accountability Act (HIPAA). Our psychiatric practice will adhere to the more stringent requirements for privacy. In fact, the Social Work Licensing Law and the Health Related Boards for Psychiatry provides extremely strong privileged communication protections for communication between a social worker, psychiatrist and client within a professional relationship, and this privilege is based upon attorney-client privilege. HIPAA provides privacy protection of your personal health information, which is called protected health information (PHI),.This is information that can personally identify you. PHI consists of three components: treatment, payment, and health care operations. These terms (and others) are defined below. DEFINITIONS PHI Protected Health Information. It is the information in your psychological record that could identify you. I and me - in this Notice, refers to your therapist, Brenda Hartgrove, LCSW and Psychiatric Services of East Tennessee, LLC. And Restoration Counseling Services. You and your - mean you and /or anyone who is legally allowed to act on your behalf. Individually identifiable health information - information created or received about you that relates to your past, present, or future health; or payment for your health care that identifies you or for which there is a reasonable basis to belief the information can be used to identify you. Authorization is a written document describing the information to be released, to whom the information is being released, the purpose the release is being made, the length of time the authorization is valid (usually one year) The authorization will be signed by you and witnessed. You may in writing revoke all authorizations to disclosed protected health information at any time. You cannot revoke an authorization for an activity already done that previous written approval was given or if the authorization was secured as a condition for obtaining insurance and under Tennessee law, the insurer is contesting the claim under the policy. Should you wish to revoke an authorization needed to pursue third party reimbursement, no future claims would be filed, and you would be responsible for all financial obligations. If you no longer desire that I provide the insurance company/managed care company with ANY information, you would also be responsible for those services that the insurance company refused to pay due to the lack of needed information. *Note: if the revoked consent involved an insurance company, any discounted fees associated with the insurance contract would no longer apply and my usual and customary fee would become effective. Treatment means providing, coordinating, or managing your care and related services including managing your care with a third party; consulting with other health care providers; or receiving a referral from another health care provider to us for your care or our making a referral for your to another health care provider. Examples include psychotherapy sessions, psychological testing, or discussions with your primary care physician or psychiatrist concerning your medication and overall medical condition. information Payment means activities I undertake to obtain reimbursement for your care. Examples include billing and collection activities, or providing information about your care to an insurance company that may be covering part of the cost of your services. Health Care Operations are activities related to the performance of my practice such as quality assurance tasks. In mental health care, one of the best examples of health care operations is when an insurance company or managed company reviews treatments records or our work to see if your care is medically necessary. This only applies if you are requesting that I file insurance for you. Other activities might include assessing the quality of my services and client outcomes; reviewing the competence or qualifications of staff or students (if applicable); arranging for my legal, accounting, and similar services; business planning and development; and the administrative activities of my practice. For example, I may compile overall statistics about clients and treatment outcomes, and if I do, such data will not include any personally identifiable. Use refers to activities within my office. Examples include using your protected health information in order to file insurance claims, schedule appointments, keep records and other tasks within my office relating to your case. Disclosure refers to release of information or activities outside this office such as releasing, transferring, or providing access to information about you to other individuals. An example would be sending your records to your primary care physician after you have signed an authorization for me to do so. USES AND DISCLOSURES OF PHI REQUIRING AUTHORIZATION As noted, Tennessee requires authorization and consent for treatment, payment and health care operations. HIPAA does nothing to change this requirement in Tennessee. I may disclose PHI for the purposes of treatment, payment and healthcare operations with your consent. You have signed this general consent to care and authorization to conduct payment and health care operations that authorizes me to provide treatment and to conduct the administrative steps associated with your care (i.e. file insurance for you). Additionally, if you ever want me to send any of your protected health information of any sort to anyone outside my office, you will always first sign a specific authorization to release information to this outside party. A copy of that authorization form is available upon request. The requirement that you sign an additional authorization form is an added protection to help insure your protected health information is kept strictly confidential. An example would be if you requested me to speak with or release records to your primary care physician. There is another special authorization provision potentially relevant to the privacy of your records: psychotherapy notes. In recognition of the importance of the conversations between a therapist and patients in treatment settings, HIPAA permits keeping psychotherapy notes separate from the overall designated medical record. Psychotherapy notes cannot be secured by insurance companies nor can they insist upon their release for payment of services as has unfortunately occurred over the past two decades of managed health care. Under HIPAA Regulations, psychotherapy notes means notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date. (45 C.F.R (65 Fed. Reg. At In summary, any psychotherapy notes maintained, would not be considered part of a medical record, and are for my use only. I may deny access to these notes unless forced to respond to by a court order. However, medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date ARE maintained in your record, and access may be requested by you to disclose this protected health information. USES AND DISCLOSURES NOT REQUIRING CONSENT OR AUTHORIZATION 1. Citizens of Tennessee including health care professionals are required by law to report knowledge of child abuse or neglect to the TN Department of Children s Services (DCS), or other agencies/officials as outlined in TN statutes (e.g. a judge having juvenile jurisdiction, office of the sheriff, or chief law enforcement official of the municipality where the child resides. 2. Suspected sexual abuse of a child: Tennessee law requires that if there is suspicion of child sexual abuse, this must be reported to DCS, etc. regardless of the whether the child has sustained any injury. 3. Adult and Domestic Abuse: Tennessee Code includes provision for Adult Protective Services that requires reporting if there is reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation. Such reports will be made to the TN Department of Human Services. An example of adult abuse ( ) might be abuse that occurred in a nursing home, while domestic abuse ( ) might be found in cases of domestic violence. TCA is voluntary (versus mandatory) reporting and may be done without disclosing the name or identity of the client/patient. 4. Judicial or Administrative Proceedings: Communication between a client and a TN licensed clinical social worker is not only confidential and private, but also considered privileged communication. Consequently, such information can only be released if you have provided written authorization OR a court order has been issued. Privilege would not apply if you were being evaluated by a third party of if the evaluation were court ordered (e.g. child custody evaluations), but if such were the case, you would be informed of these circumstances. 5. Health Oversight: Should a complaint be filed against me with the TN Health Related Board of Licensed Clinical Social Workers, the Board can subpoena confidential mental health information from me relevant to that complaint, and I would be required to release that information. 6. Serious Threat to Health or Safety: If an actual threat of bodily harm is made against a clearly identified victim, or if you are threatening to harm or kill yourself, and if I determine or should have determined that you have the apparent ability to commit such an act and are likely to do so unless prevented from doing so, I am required to take reasonable steps to predict, warn of, or take precautions to protect the identified victim (or yourself) from such violent behavior. This is Tennessee s Duty to Warn law and is also associated with national security threats. 7. Workers Compensation: Although rarely applicable to my practice, in the event that you file a worker s compensation claim and I am providing psychological care that is relevant to that claim, I am required, if requested, to provide the insurance company or your employer and to you, a complete report regarding the claimed injury. Further, this report would address the effect upon you, the treatment prescribed, estimated duration of treatment, and a statement of charges. As noted, I have a specific form to be used for your written authorization to use or disclose your health information. Request this form if you want information disclosed to you or to another person, or contact me if you want to authorize disclosure after you have finished with your treatment. This form can be mailed to you or you can stop by to complete and sign the release form. Please note in the event a release form is mailed to you, I request that this form be signed and notarized in order to confirm the signature is in fact yours. BUSINESS ASSOCIATES DISCLOSURES HIPAA requires that I train and monitor the conduct of those performing ancillary administrative services for my practice and refers to these people as Business Associates. In my practice, business associates include United Community Bank as the office space is leased from them. They do not have access to your PHI, but I felt it important that we have them sign a business associates agreement. 7

8 CLIENT S RIGHTS AND PSYCHIATRIC STAFF DUTIES CLIENT S RIGHTS: You have a right to the following: 1. The right to request restrictions on certain uses and disclosures of your PHI which I may or may not agree to, but if I do, such restrictions shall apply until our agreement is changed in writing. 2. The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want to be called at home, so you may tell us to call you at work. 3. The right to inspect and receive a copy of your PHI in my designated mental health record set and any billing records for as long as PHI is maintained in the record. 4. The right to amend material in your PHI, although I may deny an improper request and/or respond to any amendment you make to your record of care. 5. The right to an accounting of non-authorized disclosures of your PHI 6. The right to a paper copy of notices/information from me, even if you have previously requested electronic transmission of notices/information. 7. The right to revoke your authorization of your protected health information except to the extent that action has already been taken. 8. Patients have the right to participate full or to refuse to participate in community activities including cultural, education, religious, community services, vocational, and recreational activities. 9. Clients have the right to not be photographed, appear in public or make gratuitous statements on behalf of this facility. PSYCHIATRIC STAFF DUTIES 1. I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI 2. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. 3. If I revise my policies and procedures, I will post notice of this change in the waiting room of my office. Should a change occur and I receive a request for PHI, I will contact you to discuss the request and any impact of policy change. 8

9 I give permission for RCS and/or PSET to treat myself or my child. Please initial each box: I understand my insurance will be billed for this service and that I may incur a co-pay. I also understand that I am responsible for all financial obligations denied or not covered by insurance. I understand that all returned checks will be subject to a $35 returned check fee and must be picked up before my next appointment date with cash. After which, all future payments will be made with cash. I give RCS and/or PSET permission to obtain a specimen (urine, saliva, or hair) to test for any drugs and/or alcohol. I understand the No-Show Policy and that I will be charged $25 if I miss an appointment without giving 24 hours notice. I have received and understand my Patient Rights and that I may request a copy at any time. I understand that there will be an additional 25% charge on any delinquent balance due if it is turned over to a collection agency. I have been given information on transportation and health screenings that may be available free of charge to me. I understand my health information is private and confidential. I understand that RCS/PSET work very hard to protect my privacy and preserve the confidentiality of my personal health information. I understand that confidentiality does not pertain to life threatening situations, or abuse that must be reported. I understand that in certain circumstances records may be secured by a court order. I understand that I may revoke my consent to sharing my health information at any time by written request. I have been informed of the Declaration of Mental Health and it is available to me, if I would like one. I have been given copies of all the documents referred to above. I understand that a controlled substance WILL NOT be called in early, or replaced if lost or stolen. If I have a true emergency I will present myself to the nearest emergency facility. I understand that doctor shopping laws in TN requires a physician to notify authorities and patient attempts to obtain the same or similar medications from multiple physicians. It is my responsibility to disclose all current prescriptions. Please print Patient s name: If patient is 16 years or older, Patient s signature (if 16 years or older): If patient is 17 years or younger, Guardian s signature: Witness: 9

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