1 ADULT NEW PATIENT INFORMATION FORM Full Name: Date of Birth: / / Address: Best Phone: ( ) - Secondary Phone: ( ) - Preferred method of contact: Best Phone Snail Mail Sex or Gender: Marital Status: Sexual Orientation: Spouse s Name (if applicable): Employment Status: Employed Full Time Employed Part Time Student Homemaker Unemployed Disabled Retired Other Employer or School Who referred you to our practice? Emergency Contact: Best Phone: ( ) - Insurance Information (if applicable): Insurance Company Name: Insured Name Relationship: (If different from patient) ID/Member # Group Number:
2 INFORMED CONSENT FOR TREATMENT Welcome to Green Line Wellness, PLLC. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us. PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. MEETINGS I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, we will usually schedule one session (one appointment hour of minutes duration) per week, at a time we agree on, although some sessions may be longer or more frequent. Once an appointment time is scheduled, you will be expected to pay for it unless you provide 24 hours (1 day) advance notice of cancellation unless we both agree that you were unable to attend due to circumstances beyond your control. If it is possible, I will try to find another time to reschedule the appointment. Insurance does not pay for missed sessions.
3 NATURE OF THE WORK The process of undergoing therapy can be like a journey. Often times, people feel worse before they feel better. This is the nature of the work. However, because this is not an exact science, there are also no guarantees. It is important to have reasonable expectations when beginning the difficult but rewarding process of making changes in your life. The way I am able to help you the best depends on regular meetings over time. It is my expectation that you will come to therapy even if you cannot think of anything to say. If you are unable to make the majority of our scheduled meetings, I may recommend referral to another provider. If possible, I will discuss this with you. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. I work with a benefits administrator who is in charge of pre-authorization and billing of sessions for clients who use their insurance benefits. However, I am not on every insurance panel so it is important that you verify my participation on your network if you will be using your insurance benefits. Ultimately, you are responsible for maintaining coverage through your health insurance. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office on weekdays, I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by a voice mail that I monitor frequently between 10 AM and 4 PM, Monday through Thursday. I will make every effort to return your call within 24 business hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. For a quicker response, please or me directly. If you are unable to reach me and feel that you can t wait for me to
4 return your call, contact your family physician, the nearest emergency room or 911 and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. CONFIDENTIALITY In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. Additionally, filing insurance claims with your insurance provider, though they contain little clinical information, constitutes confidential protection. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client s treatment. For example, if I believe that a child, elderly or disabled person, or another vulnerable adult is being neglected or abused, I am required to file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another person or group of persons, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.
5 I understand and agree that all communication between this office and the client is held in strictest confidence UNLESS one of the following conditions is met: the client utilizes his/her insurance benefits the client authorizes release of information with a signature the provider is ordered by a court to release the information threats to harm self/others are made by the client abuse or neglect is suspected. In the latter two cases, the provider is required by law to inform legal authorities and/or potential victims. I (print name of patient) agree and consent to participate in mental health services offered and provided by a Green Line Wellness, PLLC staff member, a mental health provider. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Additionally, you acknowledge access and receipt of Green Line Wellness PLLC s Notice of Privacy Practices, which can also be found on Client Signature Date Green Line Wellness, PLLC Date Client s Printed Name Client s Guardian (if applicable) Date Rev. 8/12
6 AUTHORIZATION FOR RELEASE OF INFORMATION Name Date of Birth The undersigned hereby authorizes the release of information from the Medical and Psychological Record of the above names individual (check appropriate boxes): To and from: Green Line Wellness PLLC 714 Lyndon Lane, Suite One Louisville, KY Phone: Fax: To and from: Type of information to be released: ANY information from records Dates of Treatment Psychological Evaluation Drug or Alcohol Abuse Treatment Info Treatment information concerning HIV/AIDS infection or tests for HIV OTHER: This authorization shall remain in effect for ninety (90) days from the date it is signed by the patient. Purpose of the release: You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of treating health information for a third party. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule. Patient or Representative Signature Date Green Line Wellness Witness Date
7 PROFESSIONAL FEE POLICY Charges for services are due and payable in full at the time the services are rendered. If you have health insurance coverage, a claim form will be filed on your behalf. In the event the insurance rejects your claim, or the amount paid is less than the charges, you are responsible for paying the balance owed on your account immediately. Your account can be settled using cash, check or credit card. In the event you are unable to pay your bill in its entirety, please contact the office to make arrangements. Financial disagreements regarding child custody do not impact the below-signed individual s financial agreement with this office. Bounced checks are subject to a service fee of $25.00 per item. If a statement remains unpaid after sixty (60) days and no satisfactory arrangements have been made, the account will be sent to collections or small claims court. The cost of these proceedings will be included in the claim. Your appointment time is reserved especially for you and you must cancel with 24-hours notice to avoid a cancellation charge. If you cancel without 24-hours notice or no show an appointment, you will be charged the amount of your contracted insurance rate. Please do not come to the office sick this fee is waived in the event of illness or other circumstances at the discretion of Green Line Wellness, PLLC. Work, school and/or social obligations are not considered emergencies. There is a $25.00 charge for each fifteen (15) minutes of a telephone consultation lasting longer than five (5) minutes. Matters requiring lengthy responses are billed at the same rate. There is a $50.00 charge for each fifteen (15) minutes of the clinician s time required for filling out paperwork related to disability claims, etc. Insurance companies will not pay for these fees. (Paperwork required by your insurance company for services rendered is not subject to this fee.) If you become involved in legal proceedings that require my participation, you will be responsible for my professional time. Because of the difficulty of legal involvement, you are expected to pay a flat fee of $800.00, which covers the first two hours of court or deposition appearance and one hour of preparation time/phone calls. Additional time will be billed at $ per hour for preparation work and $ per hour for attendance at any legal proceedings. Insurance companies will not pay for this fee. By signing below I attest that I understand and agree to the professional fee policy. I am aware that I am ultimately responsible for any charges incurred for services rendered. It is my responsibility to inform this office of any changes to my insurance or billing information. Patient or Representative Signature Date
8 PAYMENT AGREEMENT Insurance (check one) I elect to use my insurance benefits for mental health services from Green Line Wellness PLLC. I give Green Line Wellness PLLC and my clinician permission to release any information needed to process my claims and collect payment for services rendered. I am responsible for amounts and/or services not covered by insurance as well as services not covered because of my responsibility to obtain a referral or authorization. Insurance companies do not cover missed appointments or phone/text/ contact and I will be responsible for any charges incurred. I understand and accept that I will be charged the full amount of my contracted insurance rate of if I do not cancel an appointment within 24 hours, do not call or come to the appointment, or late cancel not due to a bona fide emergency or illness as noted in the Professional Fee Policy. I elect not to use any insurance benefits for mental health services from Green Line Wellness PLLC. Instead, I agree to a session fee of. I understand and accept that I will be charged the full amount of the above rate if I do not cancel an appointment within 24 hours, do not call or come to the appointment, or late cancel not due to a bona fide emergency or illness. Work and/or social commitments are not considered emergencies. Payment (check all that apply) I elect to pay for my services at Green Line Wellness, PLLC with cash or a check each time. I elect to pay for my services at Green Line Wellness, PLLC via credit card, Health Savings Account card or Flexible Spending Account card each time. I understand my credit card information will not be kept on file and I will be responsible for following up with my clinician to ensure my account stays current. I elect to pay for my services at Green Line Wellness PLLC via credit card, Health Savings Account card or Flexible Spending Account card. I elect to keep my credit card information on file and authorize Green Line Wellness, PLLC to charge me for services as they are incurred. I also agree to the charges in advance and waive my right to dispute charges as long as Green Line Wellness, PLLC is following the policies set out in this document. My signature below represents my signature on an agreement to pay the owed amount according to the card issuer agreement. (Merchant agreement if credit voucher). This agreement applies to the credit card below: Name on Credit Card: Credit Card Account Number: Expiration Date: CVS # (3 digits on back) Signature:
9 ELECTRONIC COMMUNICATION CONSENT FORM Electronic communication offers an efficient way to communicate with Green Line Wellness, PLLC staff. However, this medium is not without its risks. Communication by telephone, cell phone, text, mail, , websites, fax, and the like are not secure and thus do not guarantee confidentiality. Though I take many steps to ensure confidentiality, if you choose to contact me via one of these methods, you are accepting the risk that a third party may intercept our communication. Green Line Wellness, PLLC will not be liable for improper disclosure of confidential information that is not caused by our intentional misconduct. GUIDELINES FOR USE OF ELECTRONIC COMMUNICATION , phone calls and/or texting is not appropriate for urgent matters or an emergency situation; instead please call 911 or go to your nearest emergency room. s and texts should be concise. You should schedule an appointment if the issue is too complex or sensitive to discuss via these mediums. messages will be filed electronically in the patient record. Green Line Wellness, PLLC staff members typically check messages on a regular basis, however there may be exceptions to this. Green Line Wellness, PLLC staff members will not forward patient identifiable s to others outside this practice without the patient s prior written consent, except as authorized or required by law and we will never distribute a patient s address to a third party. Green Line Wellness, PLLC is not liable for breach of confidentiality caused by the patient or any third party. Normally, there will be no charge for use of periodic, brief s or texts. Should a message require a lengthy response, regular correspondence rates will apply (see Professional Fee Policy). Inform your provider of changes in your contact information including and phone numbers. Please do not give your psychologist/therapist s address to a third party. Please do not request contact or connection with your therapist via social media sites such as Facebook or Linked In. This is potentially a violation of your confidentiality and outside the boundaries of our relationship. Please do not forward s, jokes, etc. to your clinician s address. is reserved for business matters only. Abuse of this will result in the patient being billed at the regular correspondence rate. Patient or Representative Signature Date
10 CANINE ASSISTED THERAPY AWARENESS FORM BENEFITS: I am aware that two clinicians at Green Line Wellness, Amy B. Greenamyer, PhD and Christina Bayens, PsyD, use a canine assisted therapy program. I understand that this type of program has been instituted in other patient care settings and that studies have shown that pets can have a beneficial effect on health and well-being providing companionship, love, and emotional responsiveness. RISKS: I am aware and have been informed of the fact that a live, domestic dog will be available in the Green Line Wellness, PLLC offices, but will not be in session with therapists other than Dr. Greenamyer or Dr. Bayens. I understand that the behavior and reactions of animals are not predictable, and therefore, Green Line Wellness, PLLC cannot guarantee that the dog will behave properly or that the dog will not bite, claw, scratch or otherwise inflict injury. I, also, am aware of no allergy, skin or respiratory sensitivity or other medical condition that I have which might make touching, handling or being in close proximity to the dog potentially harmful to my health. At my request, Green Line Wellness, PLLC staff will see me in another room of the building if proximity allergies exist. AGREEMENT: I have been assured that Dr. Greenamyer and Dr. Bayens have both carefully selected their dogs and that the dogs have never shown any vicious tendencies heretofore. The dogs are up to date on all vaccinations and will never be in session if ill or injured. I am aware that Dr. Greenamyer s dog is currently in training for her full pet therapy credential, but has not yet received that credential. She will be supervised at all times by Dr. Greenamyer. Dr. Bayens dog is not currently in training but will also be supervised at all times by Dr. Bayens. If I choose to greet either Dr. Greenamyer or Dr. Bayens dogs while I am at Green Line Wellness, PLLC, I agree to handle these animals gently. I will try to avoid provoking an angry response from them. I agree to assume the risk of any injury or illness resulting from my participation and agree to hold Green Line Wellness, PLLC, Drs. Greenamyer and Bayens, and the building owner, Summit Sales, & Marketing, Inc., harmless for the actions of the dogs used in this program. Patient or Representative Signature Date
11 NOTICE OF PRIVACY PRACTICES Patient Confidentiality is respected and information is only released about you in accordance with state and federal laws. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. This notice describes policies related to the use of the records of your care at this private practice facility. I am required to give you this Notice about (1) the use and disclosure of your health information, (2) my legal responsibilities, and (3) your rights concerning your health information and to abide by the terms of this notice. You may request a copy of this Notice at any time by ing to and requesting the Notice of Privacy Practices. For more information about privacy practices please contact the above address or make your request in writing to the practice address. 1. Use and disclosure of health information: The minimum necessary health information is disclosed about you for your treatment, for payment of your services and for health care operations. a. For Treatment: Health information for the purposes of referral to another health care professional for concurrent or transfer of treatment will be provided only when a signed authorization for release of information has been completed by the patient. b. For Payment: Information may need to be disclosed to obtain payment of services. For example, insurance companies or other agencies may be provided with the minimum necessary information in order for them to pay for your treatment. Should your insurance company require information other than identifying information, dates of service, diagnosis, CPT Codes and provider information, you will be asked to sign an authorization for release of information. Identifying information and balance due may also be disclosed to collection agencies in accordance with fair practices laws for small businesses. 2. Information disclosed without your consent: Under Kentucky and Federal law, information about you may be disclosed without your consent in the following circumstances. facing. a. Emergencies. Sufficient information may be shared to address an immediate emergency you are b. Judicial and Administrative Proceedings. Your personal health information may be disclosed in the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for worker s compensation. c. Public Health Activities. If it was concluded that you were an immediate danger to yourself or others, health information may be disclosed about you to authorities, as well as to alert any other person who may be in danger. d. Child/Elder Abuse. Information may be disclosed about you in relation to the suspicion of child and/or elder abuse or neglect.
12 e. Criminal Activity or Danger to Others. Information may be disclosed about you if a crime is committed on the premises or against staff or clinicians, or if it is believed someone else is in danger. f. National Security, Intelligence Activities, and Protective Services to the President or others. Health information may be released about you to authorized federal officials as authorized by law in order to protect the President or other national or international figures, or in cases of national security. g. Health Oversight Activities. Information may be disclosed about you to a health oversight agency for activities authorized by law. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting agencies may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances. h. Business Associates. The minimum necessary health information may be provided to our business associates that perform functions on my behalf or that provide this office with services if the information is necessary to perform such functions. All of my business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any of the information other than specified for the purposes of their contracted activity, such as financial auditing. i. Marketing. No information will be disclosed to a third party for the purposes of telemarketing, direct mail marketing or marketing through electronic mail. This office does not keep a mailing list for marketing purposes. j. Scheduling appointments. Your phone number or address may be used to contact you or to leave messages to schedule or remind you of appointments. Your address may be used to mail monthly statements or other billing information. 3. Your Rights Regarding Your Health Insurance: a. Right to Inspect and Copy. You have the right to look at or get a copy of your record with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred. b. Right to Amend. You have the right to request that your record be amended. Your request must be in writing and it must explain why the information should be amended. Your request may be denied under certain circumstances. c. Right to an Accounting of Disclosures. You have the right to receive an accounting of the disclosures made of your health information, for most purposes other than treatment, payment or health care operations. To request an accounting of disclosures, you must submit your request in writing. Accountings remain available for six (6) years after the last date of service. d. Right to Request Restrictions. You have the right to request a restriction or a limitation on health information disclosed about you. For example you could ask that no information shared with an insurance company in which you would be responsible to pay in full for services provided. While you are in treatment or after treatment has terminated, a written request should be mailed to 714 Lyndon Lane, Suite #1, Louisville, KY
13 Your request may be denied under certain circumstances and after serious consideration or unless the information is needed in an emergency or by law. e. Right to Request Confidential Communication. You have the right to request that communications with you about health information be disclosed in a certain way or sent to a specified address. You must make this request in writing, and it must specify the alternate means through which you may be reached. Every attempt to accommodate reasonable requests will be made. f. Right to Obtain a Paper Copy of this Notice. You have the right to obtain a copy of this notice and can make such requests through for an electronic copy or by sending your request in writing with a SASE to 714 Lyndon Lane, Suite #1, Louisville, KY Any other uses or disclosures not set out in this Notice will be made only with your written authorization. You may revoke authorization for release of information at any time by sending your revocation in writing. Revocations will become effective only after they have been received and filed and will only be for disclosures not already completed. The right to change the Privacy Practices is reserved provided applicable law permits such changes. Before the effective date of a material change, changes to this Notice will be made and dispersed. The practice is required to abide by the terms of this Notice beginning June Questions and Complaints: If you believe your privacy rights have been violated, you may file a complaint with the US Department of Health and Human Services. This notice is effective June 1, Patient or Representative Signature Date