Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX Office (817) Fax (817)

Transcription

1 PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip Code: Address: Please list telephone numbers below that are okay to call: Home: Work: Cell: Marital Status (please circle): Single Married Divorced Other Relationship to insured (please circle): Self Spouse Child Other Status (please circle): Student Full-time Student Part-time Employed Full-time Employed Part-time Retired Other If employed, name of employer: Appointment : Provider/Therapist Name: INSURED S INFORMATION Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip Code: Address: Home: Work: Cell: Name of Insurance Carrier: Insured Insurance ID #: Group/Policy/Account #: Employer Name: ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION TO INSURANCE COMPANY I HEREBY ASSIGN, TRANSFER AND SET OVER TO Provider all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, including medical, surgical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation to pay such bill if not paid by insurance company, or of any balance due payments by my insurance company. PRINTED NAME of Patient/Guardian SIGNATURE of Patient/Guardian To be completed by Healthcare Provider/Office Manager Axis 1 - Axis 2 - Axis 3 - Copy of Office/Financial Policy give to: Client; Parent/Guardian; Client Ref

2 PATIENT INFORMATION Referral source: Your main concern: Previous treatment or therapy? Yes No If yes, with: When? Do you currently experience difficulty in any of the following? Anxiety/Tension Frequent Headaches Attention Span Guilt Sleep Problems Confusion Isolation Fears Weakness Depression Dizziness Difficulty Concentrating Appetite Changes Suicidal Thoughts Memory Anger Nausea Nightmares Mood Swings Fatigue Alcohol Usage: Never Socially Occasionally Weekly Daily List your current medications: 1. Name of medication: Dosage: Times per Day: 2. Name of medication: Dosage: Times per Day: 3. Name of medication: Dosage: Times per Day: 4. Name of medication: Dosage: Times per Day: 5. Name of medication: Dosage: Times per Day: Do you use non-prescription drugs? Yes No If yes, please list: Other people living at home: Recent Changes: Identify your strengths: Emergency Contact Information: Name of Emergency Contact: Relationship: Address: Home #: Work #: Cell #:

3 PRIMARY CARE PHYSICIAN (PCP) INFORMATION Most insurance companies required Primary Care Physician information for coordination of care. 1, Do you have any medication allergies? Yes No If Yes, please list medications to which you are allergic: 2. Do you have a Primary Care Physican (PCP)? Yes No If No, no additional information on this page is needed. If Yes, please give the following information and continue to 3a or 3b: Name of PCP City 3a. I decline to have my Primary Care Physician contacted. OR 3b. Consent for Release of Confidential Information to Primary Care Physician: I, hereby authorize Your Name Name of Grapevine Behavioral Healthcare Provider to disclose to my Primary Care Physician,, Name of Physician, Address, City, State, Zip Code all clinical information about me as may be necessary to permit my Primary Care Physician to monitor the continuity of my care and to inform my Primary Care Physician of my health status. This authorization becomes effective, 201 and may be revoked by me in writing at any time, except to the extent of action already taken. Unless earlier revoked by me, this authorization automatically terminated the earliest of six months from the effective date, or the term coverage of my benefit plan. I understand that this authorization does not extend to the release of any HIV/AIDS information unless I have also placed my initials here:. I further understand that the information authorized by the Release will be released to the authorized recipient only, for the purpose noted above. I understand I (or my legal representative) am entitled to a copy of this authorization form for my records. Witness This portion to be completed by Office Personnel only. To: From: Re: : In an effort to coordinate care, I want to inform you that your patient,, was referred to me by for treatment of. Care is being delivered in the following setting: Intensive Outpatient Program Partial Hospital Program Outpatient Inpatient Unit Residential Treatment Program Other (specify) The treatment plan consists of the following modalities: Individual Psychotherapy Group Therapy Family Psychotherapy Other (specify) Please call me at (817) if you have any further questions.

4 OFFICE AND FINANCIAL POLICY CHARGES: The fee for psychotherapy appointments are scheduled at the rate of $ for the initial session and $ for each additional session. Group therapy session rate is $ Additional time spent in the session will be charged on prorated basis, however, please understand that there are other appointments scheduled after your session so extended time is usually not available. Session time is 45 minutes, the treatment time common for psychotherapy. Prorated charges will be made for phone consultations after five minutes. These charges are not billed through insurance companies and are the responsibility of the patient. CANCELLATION POLICY: A fee of $90 will be charged for appointments not kept or for appointments cancelled without a 24-hour notice. It is required that this fee be paid or payment arrangements are made prior to your appointment. Our voice mail is available 24 hours a day which allows you to leave a message at any time. Please understand that this is an office policy and is not individually negotiated by your therapist. Excessive cancellations and missed appointments may result in loss of regularly scheduled appointment time or possibly the termination of treatment. Usually there is a waiting list of clients wanting to schedule appointments and it is important for us to accommodate these clients as well. INSURANCE VERIFICATION AND AUTHORIZATION: As a courtesy, we will verify your insurance coverage and benefits. It is recommended that you contact your insurance company directly to clarify what services are covered. If pre-authorization is required for outpatient mental health services through your insurance company and/or Employee Assistance Program (EAP) visits, it is your responsibility to contact your insurance company or EAP provider to obtain this authorization. Failure to obtain an authorization number may result in your responsibility for all charges. We will bill your primary insurance only. We can provide information for you to bill your secondary insurance upon request. MANAGED CARE CLIENTS: Clients are responsible for the payment of copays at the time of each visit. If you exhaust your benefits, you may make arrangements with the office manager to personally pay for your sessions. PAYMENT: Payment is due at the time services are rendered unless other arrangements are made or if you are referred by a managed care or EAP program that covers all of your charges. Cash, checks, Visa and MasterCard are all accepted. Payment is expected at each office visit. In most cases, full payment is expected. Copayments and negotiated/managed care rates are required at the time of service. There is a $35 charge for all returned checks. Any balance not paid by your insurance company becomes your responsibility, including deductibles, exhausted benefits and pre-existing conditions. You are encouraged to contact your insurance company to be sure that you understand which services will be covered by outpatient mental health services. Please inform us if there is a situation that makes it difficult to pay your bill. Payment arrangements can be made in most cases and we are willing to work with you if necessary. An itemized statement will be mailed to you. COLLECTION OF UNPAID BALANCES: A statement of fees owed will be mailed to you as they occur. Please do not ignore these statements. Any unpaid fees may be referred to a collection agency after 45 days. If this is necessary, an additional charge of $25 will be added to your account to cover the cost of this service. FILE COPIES: There is a $45 charge for copying of files sent by an outside source. To release records, your account must be paid in full and appropriate release forms must be signed. EMERGENCY SITUATIONS: A licensed therapist is on call for clinical emergencies at all times. The emergency phone number is (817) Please leave your name, number, the nature of your emergency and the name of your therapist. Your call will be returned as soon as possible. If you do not get a return call after 15 minutes, please call again. In some cases, your personal therapist may not be available, but the therapist on call is available to help you. If a crisis occurs, please contact our office immediately so that you can get the support you need. DIAL 911 FOR ALL LIFE THREATENING EMERGENCIES.

5 OFFICE AND FINANCIAL POLICY (continued) CONFIRMATION OF APPOINTMENTS: The office does not make confirmation calls for your appointments. Please make a note of your appointment time and date. LEGAL FEES: There therapists at Grapevine Behavioral Healthcare Associates are not forensic therapists, therefore we do not specialize in court testimony. However if a therapist is subpoenaed or if therapy records are requested by the court or an attorney, the information will be provided whether or not it is favorable to the undersigned. In the event of a subpoena or request by an attorney or patient, it is fully understood that the patient will be billed $ an hour for reports, court appearances, travel and availability. If therapists are scheduled to appear and are available (i.e. cancels other appointments scheduled for that day) and the court is cancelled, the patient will be billed $ hourly for availability with a minimum of two hours paid in advance. These charges are not covered by insurance companies and are billed directly to the patient. It is required that payment is made prior to the court date and a minimum of two hours ($400.00) is paid in advance. ARD MEETINGS AND SCHOOL CONFERENCES: You can request that your therapist attend ARD meetings at your child s school to participate in educational planning and adjunct treatment. The fee is $ per hour including travel time. Your therapist may also be available for phone conferences for the same rate. These charges cannot be billed to your insurance company. EMERGENCY TELEPHONE NUMBERS: We are not equipped to provide emergency psychiatric treatment but the following facilities are available for emergency services: Baylor Hospital, Grapevine (817) Denton Regional Medical Center (940) HEB Springwood, Bedford.(817) Millwood Hospital, Arlington.(817) Cooks Childrens Hospital, Fort Worth..(682) Green Oaks Hospital, Dallas..(972) John Peter Smith...(817) Seay Center, Dallas (children and adolescents only) (972) DIAL 911 FOR ALL LIFE THREATENING EMERGENCIES. I have read, understand and agree to this financial policy and acknowledge that I have received a copy. I authorize the release of medical and other information necessary to process to insurance claims. I authorize payment of insurance benefits to Grapevine Behavioral Healthcare Associates and/or my specific provider. I will be responsible for any fees not covered by insurance. In the event that my account becomes past due, I understand that interest and collection fees may be added to my balance and an outside collection agency may be utilized. Printed Name of Patient or Parent/Guardian

6 RECEIPT OF HIPAA INFORMATION I hereby acknowledge that I have read and understand the PRIVACY PRACTICES notification as prescribed by HIPAA. I understand that HIPAA places restrictions on the release of psychotherapy notes to patient or family. Further, I understand that I may request additional information by contacting the U. S. Department of Health and Human Services at (877) Please list any others you authorize information to be released to: Printed Name of Patient or Parent/Guardian I am the (circle one) Patient Parent Guardian Other (specify) Witness

7 CREDIT CARD AUTHORIZATION I,, authorize Grapevine Behavioral Healthcare Associates to use the information and credit card numbers I have provided them to make payments for services rendered at their facility including copayment, coinsurance, No Show charges and Late Cancellation charges. If at any time I wish to terminate this agreement, Grapevine Behavioral Healthcare Associates will be notified and my credit card information will be destroyed. Witness (date signed OR verbal authorization give to Grapevine Behavioral Health Associates) Credit Card (circle one): MasterCard Visa Name exactly as it appears on the card: Credit Card Number: Expiration :