Nichol A. Moses, Psy.D., NCSP

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1 PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to our staff in contacting you, processing your billing and notifying you in case of an office closing, etc. Patient Name Maiden Name Marital Status Date of Birth SS# Parent/Guardian Complete Address City State Zip Code Length of time there Home phone # Cell Phone# Employer Work Phone # Extension Closest Relative (Not Spouse) Telephone Name of Church/Affiliation Relationship Referral Source Spouse/Legal Guardian Name ** May we contact your spouse regarding appointments? (see Courtesy call form) Address (if different from above) Date of Birth _ SS# Telephone Employer Job Title Work Telephone Extension Length of time there MEDICAL INFORMATION Primary Care Physician Name Physician s Address Insurance Carrier ID# Group Policy Holder Name Policy Holder s Date of Birth: Address (if different from above) *A 24-hour cancellation notification is required. There will be a late cancellation fee charged for appointments cancelled without at least a 24 business hour notice. This fee is NOT billable to any insurance carrier. **PLEASE NOTE: You will be held liable for any collection costs and/or attorney fees in the event those services are needed to collect this debt. ***By signing this form, you are indicating that you have read and understand the accompanying office policies. Signature Date

2 Reminder of Missed Appointment and Late Cancellation Fee Policies Our Practice requires that in the event you have to cancel an appointment, you must notify us one business day (24 hours) in advance; phone messages left with the answering service over the weekend do not qualify as 24 hours notice for Monday appointments. There is a fee for appointments canceled with less than 24 hours notice and a fee for appointments, which are missed with no contact in advance at all. Please be aware that in some cases repeat missed appointments can lead to termination of services, and none of these fees are insurance reimbursable. We would like to emphasize that there are no exceptions to the above policy. In other words, the policy applies even if there is a good reason, such as an emergency that requires you to cancel your appointment. On the other hand, we do have procedures, which may, in some instances, permit you to avoid such charges. Specifically, if you do cancel with less than 24 hours notice, we do try to find someone to take your canceled appointment. If we are successful, we do not charge the late cancellation fee. Finally, if there is a snow emergency and the police announce a driving ban, and you call in advance of your appointment to cancel, we generally waive the late cancellation fee. Emergency Procedure In case of a psychiatric emergency, you are urged to call your therapist. The process for doing so is as follows: If the call is during business hours, call , or in Orchard Park, Inform the secretary of the emergency and the office staff will attempt to contact your therapist or the therapist on call. If an emergency arises after business hours, call You will be connected with our answering service. Advise them that this is an emergency and the name of your therapist. The answering services will then attempt to reach the therapist. Please then wait a reasonable period of time. (If you cannot wait, follow your insurance company s guidelines, contact crisis services at , or go to the emergency room.) If you do not hear from your therapist in a reasonable time period, call the answering service back and request that they contact the therapist on call. Again, please wait a reasonable period of time. If the on-call therapist does not return your call and you are still experiencing a psychiatric emergency, please follow your insurance company s guidelines or go to the emergency room.

3 Outpatient Services Agreement: Client Copy Psychological Services: Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular challenges that are brought forward. It involves a large commitment of time, money, and effort on the part of you and your family. In order to be most successful, you or your child will have to work on the things we talk about not only during our sessions, but also at home. Psychotherapy can have benefits and risks. Since therapy often involves unpleasant aspects of your or your child s life, you or your child may experience uncomfortable feelings like sadness, frustration, or loneliness. On the other hand, therapy often leads to better relationships, solutions to specific problems, and significant reduction in feelings of distress. However, there are no guarantees of what you will experience. It is important that you understand that no one can completely predict the course of human relationships, and as we learn more about each other, it may be necessary to amend the modification that have been agreed to. Our first one to three sessions will involve an evaluation of recent and past events that may be impacting your or your child s current functioning. During this time, I will obtain background information and learn about your concerns. If you have any relevant written information, such as school records or previous psychological evaluations, I encourage you to bring them with you to the appointment. Together, we will decide on the treatment goals for you, your family, or your child and the frequency of visits. Please note that your child is entitled to developmentally appropriate information about their treatment including developmentally appropriate participation in decision making about their treatment. The approaches used will vary depending on the individual case. Appointments will last for approximately minutes. Professional Fees: Hourly fees typically range between $ depending on the type of services provided (e.g., consultation sessions, initial appointments, individual sessions, assessments). In addition, to weekly appointments, I charge an hourly fee for other professional services that you or your family may need, although the hourly fee is prorated if the service provided is less than one hour. Such services include consultation (e.g., attendance at meetings you have authorized with other professionals), preparation of records or treatment summaries, and the time spent performing any other service you may request of me. In such a case, I will discuss the fees with you prior to the provision of such services. These services are not typically covered by health insurance, so you will be responsible for the full amount. I recommend that you contact your insurance company beforehand to determine if your policy provides reimbursement. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge a higher hourly rate for preparation, travel time and attendance at any legal proceeding. My rate for involvement in legal proceedings is a minimum of $500 per hour (time for preparation, etc. is also charged); advance payment is required. Health Insurance & Payments: If you plan to utilize health insurance, it is very important that you familiarize yourself with your policy s requirements, limitations, and benefits. It is your responsibility, as the client, to know the extent of your insurance coverage. Should your insurance claim be denied for any reason, you are responsible for direct payment of fees. I strongly recommend that you obtain information regarding the charges you will be required to pay at each visit (co-payment), how many Behavioral Health visits per year are covered under your policy, and whether there are any limitations on the types of services covered. All insurance plans that require pre-authorization or referrals are your responsibility. If you do not obtain this, services will be billed on a self-pay basis until proper authorization is obtained. Please be aware that if they are paying for services, your health insurance company requires that I provide them with information relevant to the services I provide to you or your child. I am always required to provide a clinical diagnosis and the dates of services provided. I am occasionally required to provide additional clinical information, such as a description of the problem, treatment

4 plans, or treatment summaries. I will make every effort to release only the minimum amount of information that is necessary. If you have specific questions regarding the type of information your insurer requires, or the manner in which they protect such information, I encourage you to contact their customer service department directly. All co-payments and non-insurance covered self-pay fees are due in full at the time of service. Some individuals have the type of insurance coverage, which reimburses them directly. In this case, as with all health care, you or the designated party responsible is expected to provide payment at the time of service, with the insurance company providing reimbursement to you directly. A patient balance may not exceed one visit without prior discussion with me and my approval. In such instances, you will be notified by mail that the account must be paid or services will be interrupted after the next scheduled appointment. While I do not reduce fees, I am under certain circumstances, willing to work out various payment plans. These plans are available only under special conditions and require my prior approval. Accounts having uncollected fees due to non-payment will follow standard collection procedures. These procedures may involve the use of a collection service for non-payment accounts and/or prosecution in the case of checks being returned. In the event any unpaid debt is turned over to the collections agency, you will be held liable for any and all collection fees and/or attorney fees needed to collect the debt. Should you have any questions about billing and payment procedures, please feel free to discuss them with me or the billing department (Monday through Friday 9:00AM 4:30PM) Professional Records: The laws and standards of my profession require that I keep treatment records. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. I may be asked to provide information to a third party; it is a common occurrence that referring physicians request an initial report and possibly a progress report. Many insurance companies require your primary care physician to receive such report. Often, by signing a contract with your insurance company, you have given permission for your physician to receive such reports. For third party requests, you will be asked to sign a Release of Information form, without which I cannot send your records. It is your choice whether to sign the release. Confidentiality: Assuring your privacy is very important. I am required by New York State law and professional ethical standards to keep anything you tell me confidential. The confidentiality of all communications between a client and a psychologist is protected by law and I can only release information about our work together with others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. Except for these specific situations, we will not release any information about your treatment, including the fact that you are receiving treatment, without your written consent: Duty to Warn & Protect: When a client discloses intentions or a plan to harm another person or is behaving in a manner that, in my clinical judgment, suggests that you pose a threat of physical nature to another person, I am required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses a concrete plan and intention to commit suicide or if in my opinion, there is a substantial risk of suicide, I am required to notify legal authorities and make reasonable attempts to ensure the safety of the client. If you disclose intent to commit a crime, privilege is waived; I will not tacitly aid or abet in the commission of crimes. Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, I am required to report this information to the appropriate social service and/or legal authorities. These situations are quite rare in my practice. Should such a situation occur, I do make every effort to discuss with you my intended actions prior to making any disclosures.

5 Legal Proceedings: If you are involved in a legal case in which your emotional health may be an important issue, your records may be subject to a subpoena. Your records may also be subject to subpoena if you are involved in a criminal matter. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) that I provide for use and disclosure of PHI for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our work together can begin. We can discuss any questions you have about the procedures after you have read the entire document. When you sign this document, it will represent an agreement between us. You may revoke this Agreement in writing at any time. The revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred.

6 MISSED APPOINTMENT FEE AND LATE CANCELLATION FEE POLICY I _, have read the above information that explains the missed appointment fee and late cancellation fee policies. I understand that at least 24 hours cancellation notice is required to avoid a missed appointment fee or late cancellation fee. In the event that I do not give such notice, only the following condition will waive the fee: 1. If the appointment is filled with another client. By signing this form, I understand that there are no exceptions to the above policy, including even if there is a good reason, such as an emergency situations that requires me to cancel my appointment. By signing this form, I understand that I am responsible for this fee and it is not billable to my insurance. I have discussed these fees with my therapist and fully understand them. Name (print): Signature: Date:

7 Payment Policy Please be aware that as of September 1, 2008 a $5 (five) billing fee will be added to your account if your co-pay is not made at the time of service or before the office closes that day. Please note that an additional fee will also be added each month that the balance still remains (this mean that if you have a $10 co-pay and the balance still remains after two months the billing fees will equal an additional $10 making the total balance $20). If you have any further questions please feel free to contact our Billing office between 9am and 4pm. Name (print): Signature: Date: (Administrative Assistant s Initials)

8 Courtesy Calls It is the preference of most clinicians at Western New York Psychotherapy Services to have the secretarial staff make courtesy calls to most of our patients one or two days before their appointment. This is to serve as a reminder call. It is not always possible to make courtesy calls, due to secretarial workload. Also, there are times when we make an effort to contact our patients but do not succeed, due to incorrect numbers, no answering machines, changed numbers or other reasons that may prevent us from successfully contacting you. There have also been, on extreme occasions, times when we were unable to make the calls, due to weather, illness, or other unforeseen circumstances. We wish to make it clear that, although we try to call on a regular basis, you are responsible for the making, keeping, and/or canceling appointments in a timely fashion. Release of Liability: We would like to know if you want to be on our courtesy call list. Please place your name, and number to call below. The only information disclosed will be the clinician s name, and the date and time of the appointment. Please fill out the following below: Please check whether you d like to receive a courtesy call prior to your appointment: Yes No Number: ( ) Be aware that by signing this form you are releasing us from any liability associated with leaving information regarding your or your child s appointment. Name (print): Signature: _ Date:

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