Legal first and last name of person being assessed today: Marital Status: Social Security #: State: Zip: Employer:

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1 Admissions Staff Place Patient ID Sticker Here Patient Registration Please read and complete both sides of this form Date: Time: Legal first and last name of person being assessed today: Date of Birth: Age: Sex: Race: Marital Status: Social Security #: County: Phone #: Address: City: State: Zip: Employer: Emergency Contact Relationship: Phone # _ Address: How did you hear about Holly Hill Hospital? What type of treatment are you seeking today? Have you been a patient at Holly Hill in the past? How long ago? Guarantor/Guardian Name: Relationship: Check if information is the same as patient Guarantor/Guardian Phone Number: Guarantor/Guardian Address: Insurance Information Primary Insurance: Name of policyholder: Policy #: Group#: Date of Birth: SS# of policyholder: Employer: Secondary Insurance: Name of policyholder: Policy #: Continued on Back

2 Please Provide us with Information on Your Network of Support: Please list your treatment providers below. (Circle the appropriate credentials for each provider.) PROVIDER 1: Psychiatrist/Psychologist/Therapist/SW: City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months PROVIDER 2: Psychiatrist/Psychologist/Therapist/SW City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months PROVIDER 3: Psychiatrist/Psychologist/Therapist/SW: City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months If Child/Adolescent List School Name Would you like information provided to your provider network? Yes No STAFF USE ONLY Release of Information Signed during admission for ALL providers: Yes No, patient declined No providers Outpatient Providers contacted by Intake staff during admission process via: Direct call Voice mail Unable to reach or leave voic Patient declined No providers Staff Signature: Date/Time: Notes:

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4

5 Signing below only acknowledges receipt of Holly Hill Hospital s Notice of Privacy Practices. Name of Patient (Print or Type) Signature of Patient Date Time Signature of Authorized Personal Representative Date Relationship Signature of Witness HHH Employee Date /Time

6 Holly Hill Hospital Consent to Use and Disclose Protected Health Information Use and Disclosure of Your Protected Health Information Your protected health information will be used by Holly Hill Hospital or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the hospital. Notice of Privacy Practices You should review the Notice of Privacy Practices for more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your protected health information. Holly Hill Hospital may or may not agree to restrict the use or disclosure of your protected health information. If Holly Hill Hospital agrees to your request, the restriction will be binding on the facility. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices Holly Hill Hospital reserves the right to modify the privacy practices outlined in the notice. Signature of Patient or Authorized Personal Representative I have reviewed this consent form and give my permission to Holly Hill Hospital to use and disclose my health information in accordance with it. Name of Patient (Print or Type) Signature of Patient Date Signature of Authorized Personal Relationship of Authorized Personal Representative/Parent/Legal Guardian Representative to Patient Signature of Witness HHH Employee Date /Time Form # Rev. 9/15

7 HOLLY HILL HOSPITAL FINANCIAL AGREEMENT The undersigned hereby agree as follows: 1) GUARANTEE OF PAYMENT: Holly Hill Hospital (HHH) and the Physician/Healthcare Professional identified above has been or will be providing care to the patient whose name appears above. I hereby agree to guarantee the payment of the bill for services rendered by HHH and the Physician/Healthcare Professional. I agree whether signing as guarantor or as patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account of HHH and the Physician/Healthcare Professional in accordance with the regular rates and terms of HHH and the Physician/Healthcare Professional. Should the account be referred for collection by an attorney or collection agency, I agree to pay all attorney fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when due. 2) ASSIGNMENT OF INSURANCE BENEFITS: In consideration of medical services rendered or to be rendered by HHH and the Physician/Healthcare Professional, to the extent permitted by law, I hereby (I) irrevocably assign, transfer, and set over to HHH and the Physician/Healthcare Professional (II) all of my rights, title and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility and (IV) to have an individual policy continued or issued in accordance with the terms and benefits under any insurance policy, subscription certificate or other health indemnification agreement otherwise payable to me for those services rendered by HHH and the Physician/Healthcare Professional during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy(ies) of insurance, but shall not be construed to be an obligation of HHH and the Physician/Healthcare Professional to pursue any such right of recovery. I hereby authorize the insurance company(ies) or third party payer(s) providing coverage for services to pay directly to HHH and the Physician/Healthcare Professional all benefits due for service rendered. 3) Authorization to Use and Disclose Protected Health Information for Payment Purposes: I hereby authorize the use or disclosure of the information identified herein, which may include information regarding drug/alcohol abuse, treatment and rehabilitation, psychological or psychiatric impairments, physical conditions, HIV, and/or AIDS, and other communicable diseases by HHH for payment purposes. The information to be used or disclosed includes those records which are necessary to support claims for payment or reimbursement for services provided to Patient. I understand that I may revoke or terminate this authorization at any time by submitting a written revocation to the HHH Privacy Official, except to the extent that action has already been taken in reliance thereon. If not previously revoked, this authorization will automatically expire six months following discharge. I hereby acknowledge that this consent is voluntary and that there are statutes and regulations protecting the confidentiality of authorized information. 4) INSUFFICIENT INSURANCE COVERAGE: If any insurance or other third party coverage which the patient may have rejects the patient s claim or pays only part of the claim, the undersigned shall be responsible for payment of the balance due, as determined by HHH and the Physician/Healthcare Professional. 5) I acknowledge that this agreement has been read and is understood. I further acknowledge an understanding that the physician s charges will be billed separately from or in addition to charges that may be billed by HHH or other licensed Healthcare professionals who may provide services to the patient. FOR MINORS OR OTHER DEPENDENTS COVERED UNDER PARENTAL GROUP HEALTH PLANS For married parents of patient, please supply the following information: Mothers DOB Fathers DOB For separated or divorced parents of patient, the separation agreement or divorce decree places legal custody with: I CERTIFY THAT THE INFORMATION SUBMITTED ON THIS FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE AND I AGREE TO ALL OF THE PROVISIONS SET FORTH IN THIS FINANCIAL AGREEMENT. Patient Name Please Print Date Signature of Patient (Over 18 years old) Parent/ Legal Representative/Guarantor Please Print Date Signature of Parent/Legal Representative/Guarantor Signature of Witness HHH Employee Date/Time Form # HH9061 9/2015REV

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