PATIENT INFORMATION SHEET

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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) Relationship Telephone Name of Church/Affiliation 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 Kerstin H. Block, Psy.D. MISSED APPOINTMENT FEE AND LATE CANCELLATION FEE POLICY I, understand that 24 hours notice for a cancellation is required to avoid a Missed Appointment Fee of $70.00 or a Late Cancellation Fee of $ Sundays & holidays require an additional 24 hours notice. I understand that this fee is not a penalty, but has been established to offset cost of reserved therapist time. I am responsible for this fee and it is not billable to my insurance. This fee is unrelated to reason for cancellation. Signature Western New York Psychotherapy 2

3 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. If we are able to reschedule your appointment in the same business week, there is no late cancellation fee or missed appointment charges. 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 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. Western New York Psychotherapy 3

4 COURTESY CALLS It is the preference of most clinicians at Western New York Psychotherapy 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: Name (Print): (Name of Client / Guardian) 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. Signature: Date: Western New York Psychotherapy 4

5 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. (Patient Signature) (Date) (Print name) (Receptionist Initials) Western New York Psychotherapy 5

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