NEW CLIENT INFORMATION

Transcription

1 page 1 of 9 Administrative Use Only Clinician Assigned: Date/Time of First Session: NEW CLIENT INFORMATION Client s Full Name: Date of Birth: Social Security # (required): Street Address: State: City: Zip Code Home Phone (required): Cell: Family Member Names Dates of Birth (mm/dd/yy) Relationship Phone Number and/or INSURANCE INFORMATION - *Please present your card upon first visit If insurance is not being used, please check here Name of Insurance Plan*: ID Number: Group Number: Single or Family Coverage: If Family coverage, please list all covered members: Policy Holder Name: Policy Holder Date of Birth: Policy Holder Social Security # Policy Holder Employer: Policy Holder Home Address and Phone (if different from client s contact information): Rev

2 Page 2 of 8 If a person other than the individual completing this Edgewood Clinical Services New Client Paperwork and signing the consents for treatment for the presenting client is responsible for fees, please direct them to contact our Billing Department to make arrangements for alternative payment plans.edgewood Clinical Services Billing Department can be reached at Ext. 304 or billing@edgeclinicalservices.com. Please provide the contact information for the individual we should expect to hear from below. By providing the information below, you are consenting for Edgewood Clinical Services staff to communicate with the indicated individual and acknowledge participation in treatment for billing purposes only. No clinical information will be shared. If consent is not received from the person below, the individual presenting and initiating services will be responsible for all charges incurred as also indicated in our financial statement. Name: Relationship: Phone: Address: Signature of Client/Responsible Parent or Legal Guardian Date If you or your family members are covered under any other medical plan in addition to the coverage listed above, please complete the following section: Health Plan Name Name of Person Covered Policy Number Effective Date ADDITIONAL CLIENT INFORMATION Who referred you to Edgewood Clinical Services? Please list medical conditions that the identified client has: Please list any prescription medications that the client takes: Please note any difficulties that you would like the Clinician to address with you (including history of trauma and substance use) or the identified client in session. Please be aware any or all of what is listed may not be addressed in the first session but will be discussed as clinically appropriate:

3 3 of 9 CONSENTS AND NOTIFICATIONS INFORMED CONSENT FOR SERVICES Edgewood Clinical Services provides counseling services to all age groups. We also provide psychological testing and case coordination for families who would like to use these services. All clinicians strive to be accessible by phone or , but please be advised that we DO NOT offer 24 hour emergency crisis coverage. Please leave a message or send an to a clinician to keep contact with them on an ongoing basis. If there is an emergency, please visit your nearest emergency room, or call 911. PATIENT RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPPA) I have received a summary of the Notice of Privacy Practices for Edgewood Clinical Services. I have been made aware that I may request a copy of the complete notice at any time. I am also aware that the notice is available on the practice website at CONSENT FOR TREATMENT As a client, I consent to the evaluation and treatment process with Edgewood Clinical Services, and I understand that this process may include myself, my spouse, my children, and/or other family members. I understand that I have the right to withdraw from treatment at any time. I understand that if I am a divorced parent of a child, my ex-spouse will be informed of our child s treatment at Edgewood. All future contact and treatment will be based on clinical necessity when meeting with our assigned therapist. I understand that the number of visits I receive will depend on the type(s) of issues that exist, the recommendations made, and the effort that I (client) puts forth by following suggested recommendations. APPOINTMENTS Appointments will be scheduled at a time mutually acceptable to both the client and the therapist. 24-hour advance notice of cancellation is required, except in cases of extreme emergency. Appointments missed or canceled with less than 24 hours notice will result in a charge of $40.00 for clinical sessions, $40 per hour for psychological sessions and $75 for psychiatric sessions. If a check is returned for insufficient funds, the client is responsible for the $25 bank fee. An alternative method of payment will be required. POTENTIAL EXPENSES When possible, Edgewood will bill your health insurance for services rendered. Below are fees that may be charged to the client directly because your insurance company may not cover them. Phone Consultation min: $50 Phone Consultation 30+ min: $80 Copying of Records: $30 Written Correspondence: $80 Attendance at IEP or other off-site meetings: $150 per hour (includes travel) INSURANCE As a Client, I understand that Edgewood Clinical Services will verify my insurance benefits and coverage. I understand that I am solely responsible for out of pocket costs that may be incurred, and the benefit information that Edgewood Clinical Services may relay to me from my provider is not a guarantee of coverage or benefits. As a Client, I authorize the release of any medical or other information necessary to process my insurance claim. I also authorize payment of medical benefits to the supplier of services provided to myself, child, or family. I understand that billing will be submitted to insurance under the provider with whom I see, or the supervisor of that provider. Questions should be directed to our Billing Department.

4 Page 4 of 9 ELECTRONIC COMMUNICATION By initialing below, I (client) agree to allow the staff at Edgewood Clinical Services to communicate with me via with the address provided, and give Edgewood permission to send an e-newsletter to this address (client can opt out at any time). I understand that electronic communications are not completely secure, and that any information that may be stolen is not the responsibility of Edgewood Clinical Services. I also understand that if I choose to communicate with Edgewood staff via text messaging, social media sites, or other modes of communication that I assume all risks associated with the chosen method of communication. CONFIDENTIALITY To provide effective treatment for the client s needs, the therapist will ask many personal questions. You can be assured that all personal client information is kept STRICTLY CONFIDENTIAL. Absolutely NO CLINICAL INFORMATION about your case will be released to anyone without your written authorization and consent. Licensed Psychologists, Clinical Social Workers, and Counselors in the state of Illinois are required by law to report any suspected child abuse or neglect. They are also required to make a report if a client is a lethal danger to themselves or others. As a client, I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that all communication with other providers or individuals can be made by Edgewood Clinical Services only by my signed or verbal consent. My signature below reflects my understanding and acknowledgment of the aforementioned Edgewood Clinical Services consents and notifications. Client Signature: (Client 12 & over) Parent/guardian Signature: Date: Date: Rev

5 page 5 of 9 FINANCIAL STATEMENT Edgewood Clinical Services is committed to providing the highest quality of counseling and psychological services to all of its clients. In order to do so, Edgewood Clinical Services and its clients must understand the benefits provided to a client by an insurance provider. Many insurance plans have deductibles, co-insurance, and co-pay amounts that are the client s responsibility; deductibles must be met before insurance will begin to cover the cost of counseling. These deductibles apply to ALL medical providers; they are not isolated to mental health. In cases where a person or family does not have insurance to help cover services, Edgewood Clinical Services and the client must have a clearly outlined fee for services rendered. It is understood that fees under this type of agreement will be paid in full by the client. Edgewood Clinical Services wishes to ensure that all families can have access to services. If there are circumstances that prevent a client from meeting the financial obligations of obtaining services, they should contact our Billing Department to explore payment options. Edgewood Clinical Services does require prompt payment for services provided, and all accounts that have not received a payment towards the account balance within 90 days of the date of service will have the credit card on file charged accordingly. If an account, for any reason, goes beyond 90 days past due, and a payment plan has not been arranged, your balance may be forwarded to a collections agency without your notice. My signature below reflects my understanding of the financial policy at Edgewood Clinical Services. Client Signature: (Client 12 & over) Parent/guardian Signature: Date: Date:

6 Page 6 of 9 CREDIT CARD ON FILE POLICY All Clients are required to keep a credit card on file with Edgewood Clinical Services in order to receive services. Simply because there is a credit card on file does not mean that we will bill your card every month. If you wish to pay by check, cash, or PayPal, that is acceptable. The credit card that is on file will be charged for all outstanding balances greater than 90 days past due if no payment arrangement has been made. It can also be used should a payment plan be arranged with our staff. Please initial the choice of how you would like your credit card used below: 1) Please charge my card per session for all copays and non-covered service charges, and monthly for all co-insurance, or deductibles that have accrued. 2) Please charge my card on or about the first of each month for all balances in full that are past due for greater than 90 days. Credit Card Information Please be sure to complete all sections: 1) Card Holders Name 2) Credit Card Number 3) Expiration Date 4) Security Code (3 digits on back of card, 4 digits on front if AmEx) 5) Billing Zip Code of Credit Card 4) Visa, MasterCard, AmEx, or Discover (circle one, flex spending accepted) 5) Card Holders Signature Date 6) Card Holder Phone number I understand that by signing above, I am authorizing Edgewood Clinical Services to charge my card in the manner indicated by my initials above. These balances may include co-pays, co-insurance amounts, or deductibles. I understand that Edgewood Clinical Services will me a receipt from my credit card as proof of payment. Edgewood will contact me if my card is declined or expired should I fail to update this information. Credit card information is immediately stored at PNC Merchant Services. Once entered your original document is destroyed for your privacy. Rev

7 page 7 of 9 CONSENT TO RELEASE INFORMATON TO OTHER MEDICAL PROFESSIONALS I hereby give my consent to communicate with my own or my child s Primary Care Physician (PCP) or other relevant health care provider about treatment. Other providers will only be contacted after it is discussed directly in session between the client and the counselor. OR I choose to refuse permission and do not prefer to have any other medical providers contacted regarding my care at Edgewood Clinical Services. If Consent Is Given, Please Complete Below: Primary Care Physician: Name: Address: Phone: Specialty: Health Care Provider #2 Contact Info: Name: Address: Phone: Specialty: Health Care Provider #3 Contact Info: Name: Address: Phone: Specialty: Client Signature: (Client 12 & over) Parent/guardian Signature: Date: Date: Edgewood Clinical Services 2948 Artesian Road, Ste. 112, Naperville, IL Phone: Fax:

8 Page 8 of 9 GENERAL CONSENT FORM In certain cases, clients may want Edgewood Clinical Services to be able to discuss files with school personnel, ex spouses, legal guardians or other healthcare practitioners. Please complete if there is anyone with whom you would like your clinician to be able to exchange information with. Please note that completion of this form is not a requirement for treatment. RELEASE OF INFORMATION I,, authorize Edgewood Clinical Services: (Client or client guardian) to give information to to receive information from Name: Organization: Address: City: State: Zip: Phone: Regarding (Client Name): This information to be exchanged from to or for 12 months from signature date. Client Signature: (Client 12 & over) Date: Parent/guardian Signature: Date: Edgewood Clinical Services 2948 Artesian Road, Ste. 112, Naperville, IL Phone: Fax: Rev

9 page 9 of 9 CONSENT FOR SMS/ NOTIFICATION Edgewood Clinical Services now offers appointment reminders and account status updates through SMS and . These messages will arrive from and your normal cell charges will apply. By completing the information below, you are consenting to the receipt of above stated notifications. For each family member receiving services, an individual consent form must be completed in order to receive automatic notifications via text and/or . Select one method to receive your notifications: Client Name: Text message Mobile Number: Only one phone number can be used. OR message Address: Only one address can be used. Client Signature : Date: Parent/Guardian: Signature Date: If you wish to discontinue this notification at any time please contact our practice manager by at info@edgewoodclinicalserivces.com. Office Use Only