THERAPY AGREEMENT CERTIFICATION AND AUTHORIZATION
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- Jean Wade
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1 THERAPY AGREEMENT In order to make our relationship a successful one, please review the following information and ask any questions that you may have at this time. SESSION LENGTH Initial sessions are minutes in length. Subsequent sessions are 45 minutes in length. Groups are 1 hour in length. If you are late to your session, I will be glad to see you, but due to scheduling restrictions I can not extend the length of your session. CANCELLATION, DENIAL, AND FINANCIAL POLICY Milgrim and Associates, P.C. has agreements with a variety of insurance companies. Prior to your initial visit Milgrim and Associates, P.C. will verify benefits, co-pays, and preauthorization requirements. However, in the past insurance companies have given incorrect information. This has resulted in substantial bills for clients. Please contact your insurance company immediately if you have not already done so to verify your benefits. Milgrim and Associates, P.C. will gladly file insurance claims on your behalf. However, if your insurance company denies any claims, you will be responsible for the full amount of the visit ($150 for initial visit, $120 for subsequent individual visits, $50 per group). When an appointment is scheduled that time has been set aside solely for you, therefore canceled and/or missed appointments will result in a Missed Appointment fee of $60, except in cases of emergency. After 2 missed appointments, regardless of reasons given, Milgrim & Associates, P.C., reserve the right to charge a missed appointment fee and/or recommend possible case closure for multiple cancellations. This will be handled on a case by case basis. Insurance companies will not pay for missed appointments. Insurance companies will not pay for any time spent writing letters, reports, or making phone calls. Milgrim and Associates, P.C. will be glad to provide these services at the rate of $30 per 15 minutes. There will be a $35 charge for returned checks. I understand that reasonable efforts will be made by Milgrim and Associates, P.C. to collect these fees from me. In the event that it becomes necessary for Milgrim and Associates, P.C. to forward this account to a collection agency, I authorize my demographic and financial information to be released and agree to pay all collection agency fees, a 50% agency fee, court costs and attorney fees. CERTIFICATION AND AUTHORIZATION I certify that the above information is correct. I authorize the release of any medical information necessary to process insurance claims. I request that payments be made directly to Milgrim & Associates, P.C. on my behalf. Therefore my signature will be on file with my insurance company. SIGNATURE: DATE:
2 HIPAA Privacy Notification I have been provided a Notice of Privacy Practices that fully explains the uses and disclosures that Milgrim and Associates, P.C. will make with respect to my individually identifiable health information. I understand that I have the right to review the Notice before signing this consent. Milgrim and Associates, P.C. has afforded me sufficient time to review this Notice and has answered any questions that I have to my satisfaction. I also understand that Milgrim and Associates, P.C. cannot use or disclose my individually identifiable health information other than as specified on the Notice. I also understand, however, that Milgrim and Associates, P.C. reserves the right to change its notice and the practices detailed therein prospectively (for uses and disclosures occurring after the revision) if it sends a copy of the revised notice to the address that I have provided. Cellular Telephone Communication Notification Milgrim and Associates, P.C. utilizes cellular telephone communication. Due to the nature of cellular telephone communication, telephone calls on cellular telephones are subject to the possibility of unintended disclosure. Therefore, calls made on cellular telephones can not be considered secure. Milgrim and Associates, P.C. will not disclose Protected Health Information on cellular telephones unless specifically requested to do so by patients. The following telephone numbers are cellular telephone numbers: 1. (571) I understand that telephone calls made to this telephone number are not secure. I may request at any time that telephone calls with Milgrim and Associates, P.C. be made from a secure land line. Milgrim and Associates, P.C. will comply with these requests at the earliest possible time. Contact by Telephone and Messages I authorize Milgrim and Associates, P.C. to leave messages on my home or cellular telephone regarding presence in treatment and appointments. I authorize Milgrim and Associates, P.C. to leave messages on my work telephone with the name of the provider and a request to return the call. Patient Signature Printed Name Date
3 DEMOGRAPHIC INFORMATION INTAKE BIOGRAPHICAL DATA Name: Date: Address: Phone (Home) (Work) (Cell) (Pager) Date of Birth: Age: Gender: Social Security # Marital Status: Guardianship (Where applicable) Family Members: Name Age Sex Relationship Employer or School: Occupation or Grade Referral Source: Primary Care Physician: Phone: Emergency Contact: Phone: Relationship to Client: Allergies: Current or Chronic Medical Problems: Current or Past Mental Health Treatment (Please Include Name of Providers, Approximate Dates of Treatment, and Diagnoses): Current Medications (Including name, dosage, name of prescribing physician) Developmental History Adults complete about self if information is known Was pregnancy normal? Was birth premature? Birth weight normal? Any use of alcohol, tobacco, or other drugs during pregnancy? Born addicted?
4 Require care in neonatal intensive care unit? Routinely followed by a pediatrician for first five years? YES NO Any congenital defects, speech, vision or hearing difficulties? Growth and development occur within normal time frames? Begin school as scheduled? Ever held back? Learning disabilities (IEP)? Diagnosed with ADHD? YES NO Age Tendency towards violence towards self/others/animals? Client/Guardian Signature Clinician Signature
5 Milgrim & Associates, P.C Darby Brooke Court Woodbridge, VA Informed Consent for Treatment I, (name of client or guardian), agree and consent to participate in behavioral health care services offered and provided by Steven Milgrim, Licensed Professional Counselor and Licensed Substance Abuse Treatment Practitioner. I understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within: (1) the scope of the provider s license, certification, and training; or (2) the scope of license, certification, and training of the behavioral health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. I understand that behavioral health care is a cooperative process, and I agree that I will attend sessions regularly, share openly and honestly with the provider, and make my wishes regarding treatment known. I am aware that behavioral health treatment may temporarily intensify my symptoms, and I agree to inform the provider of any changes that may occur. I further understand that I have the right to decline any services offered or suggested to me by the provider, and I may terminate treatment at any time. I agree to discuss termination of treatment with the provider prior to discontinuing treatment, as premature termination of treatment may have adverse effects. I am aware that if at any time the behavioral health care provider, in his professional opinion, deems me a threat to myself or others, the provider will take appropriate steps to insure the health and safety of myself and others. Signature Date Printed Name Relationship to Client
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7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY
Center for Psychology and Counseling Chart # 118 E. Sunbridge Drive, Fayetteville, AR (479)
Center for Psychology and Counseling Chart # 118 E. Sunbridge Drive, Fayetteville, AR 72703 (479) 444-1400 Patient Name DOB Sex Today s SS# Marital Status: Allergies Responsible Party Address City _ State
WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )
WELCOME TO OUR OFFICE Patient s Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) Email: Personal Work DOB: Age: SSN#: Ethnic Background:
Patient Intake Form. How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance. Friend/Patient Referral Drive- By Other
Patient Intake Form How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance Friend/Patient Referral Drive- By Other If a Friend or Doctor referred you, please give us their
Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION
Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION Client Information: First MI Last Address City ST Zip Home ( ) Work ( ) Cell ( ) Okay to call or leave message at: home: Yes No work: Yes No SS# DOB
Family address preferred for patient portal access:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB
Patient Information. Patient Name: Address . City State Zip. Birthdate Sex: Female Male Marital Status: Married Single Other
Patient Information Patient Name: Address Email City State Zip Birthdate Sex: Female Male Marital Status: Married Single Other Home Phone Work Phone Cell Phone Student Status: Full Time Part Time None
GENERAL INFORMATION. Our office is located on the southwest corner of Shaw Ave. and Teilman between Fruit and West.
I would like to welcome you to my practice and am pleased to have you as a patient. I am providing you with this informational letter to help you understand how this office operates. Every effort will
KORT New Patient Information
KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School: Employer
GAINESVILLE PHYSICAL THERAPY NEW PATIENT REGISTRATION HOW DID YOU HEAR ABOUT OUR CLINIC? PATIENT INFORMATION
GAINESVILLE PHYSICAL THERAPY NEW PATIENT REGISTRATION **PLEASE PRINT CLEARLY AND FILL IN ALL INFORMATION** HOW DID YOU HEAR ABOUT OUR CLINIC? Doctor (name) Family Member (name) Friend (name) GPT STAFF
Minor Registration Forms Please Print Legibly. Demographics. *Patient Last Name: *First Name: Middle Initial:
*Indicates Required Fields Minor Registration Forms Please Print Legibly Demographics *Patient Last Name: *First Name: Middle Initial: *Date of Birth: / / *Gender: Male Female *Prefix: Mr. Miss Ms. Mrs.
550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax pathgroupatl.com
550 Pharr Rd NE, Suite 605 Atlanta, GA 30305 Office 404.235.5982 Fax 678.705.2756 pathgroupatl.com ADULT PATIENT REGISTRATION INFORMATION AND GUARANTOR AGREEMENT Which Provider are you seeing today? Smitha
MacInnis Dermatology New Patient Registration Form
MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First