NICOLAS WARNER, Psy.D.

Transcription

1 PLEASE PRINT LEGIBLY Client Information How Did You Hear About Dr. Warner? Full Client Name Home Phone Voice Message OK? YES NO Cell Phone Voice Message OK? YES NO Work Phone Voice Message OK? YES NO Preferred Phone HOME CELL WORK OK to ? YES NO of Birth Social Sec # Race/Ethnicity Gender Marital Status Religion Employer Emergency Contact Relationship To Client Home Phone Cell Phone Work Phone Client Information Revised January 2013

2 PLEASE PRINT LEGIBLY Billing Information and Consent Full Client Name Payment Method SELF-PAY INSURANCE IF USING INSURANCE Insurance Co. Ins. Plan Name Policy Holder Name Relationship To Client ID # Group # Phone Claims Policy Holder Employer Standard Fees $225 for initial diagnostic evaluation $175 for individual psychotherapy session Payments and Co-Payments Payments or co-payments are due at the time of the session. I accept cash, check, credit card (both in-office or via the Fees page of my website), and electronic funds transfer (also via the Fees page of my website). Insurance You are ultimately financially responsible for all charges whether or not paid by your insurance company and responsible for contacting your insurance company if there are problems with reimbursement. If I accept your insurance, I ask that you pay me the appropriate co-payment at the time of the session and I will bill your insurance company Billing Information and Consent Page 1 of 2 Revised January 2013

3 the remainder according to the terms I have negotiated with them. If your insurance company does not pay me, you will be billed at my standard rate minus any payments you have already made. Policy for Late Cancellations and Missed Appointments Your appointment times are reserved for you and missed appointments delay our work together. I consider our sessions very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please attempt to give at least a week's notice. I charge my standard fee for missed appointments and cancellations if there is less than 24 hours notice given unless we agree that unusual circumstances occurred. Please note that the reason behind this policy is to protect the provider's time, not to penalize you financially. Cancellations by will NOT count as notice, unless I confirm by reply . Insurance will not pay for missed or cancelled appointments. Billing Services I may contract with a billing service to handle eligibility verification, submission of insurance claims, and other general billing functions. Billing contractors have access to only the minimum amount your personal health information necessary for them to perform their jobs. Billing contractors also sign a confidentiality contract meaning they are obligated to maintain the confidentiality of your personal health information. I reserve the right to use collection services for unpaid accounts when efforts to collect past due fees have failed. Payment Policy Changes You will be notified in a timely manner of any changes to my payment policy. I,, agree to the billing policies specified above and directly assign to Nicolas Warner, Psy.D. all insurance benefits, if any, payable for services rendered. I understand I am financially responsible for all charges whether or not paid by my insurance company. I hereby authorize Dr. Warner, and his billing contractor, to release all personal health information necessary to secure payment of benefits. I authorize the use of my signature on all insurance submissions. Billing Information and Consent Page 2 of 2 Revised January 2013

4 Credit Card Authorization Form PLEASE PRINT LEGIBLY Full Client Name Name as it appears on card Card Type Visa Mastercard Discover American Express Credit Card Number Expiration CVV Code Billing I,, hereby authorize Nicolas Warner, Psy.D. to place my credit/debit card on file in order to pay for any and all payments, copayments, coinsurance, deductibles, missed session fees, late cancellation fees, or outstanding balances on my account. I understand that I am financially responsible for all missed session fees when I do not contact Nicolas Warner, Psy.D. via , telephone, voic , or letter at least 24 hours in advance of my scheduled appointment. I understand that the card will be charged after Nicolas Warner, Psy.D. contacts me via , telephone, voic , letter, or informs me in person that the charge will occur. I also understand that my credit card will not be used in any other way and that this credit card information will be stored in my confidential chart and properly secured in a locked cabinet. I understand that I will be able to provide payment through the method of my choice on current balances, however, outstanding balances that are past due 30 days will be charged to the credit card on file, unless other arrangements have been made. This authorization is valid until I provide Nicolas Warner, Psy.D. with a written notice of cancellation. I also understand that in the event my card declines, I will be required to provide a different method of payment. I will also be expected to pay for any previously unpaid charges resulting from the decline, in addition to the current charges. Witness Signature Credit Card Authorization Form Revised August 2015

5 Authorization and Informed Consent Please carefully read and keep the attached Notice of Privacy Policies and Practices for your records and return this signed form to Dr. Nicolas Warner. Full Client Name (please print) I. INFORMED CONSENT TO EVALUATION AND TREATMENT I,, agree that this authorization shall serve as my informed consent to receive psychological evaluation and treatment. II. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIES AND PRACTICES I,, acknowledge that I have received the attached notice of Dr. Nicolas Warner s policies and practices to protect the privacy of my personal health.

6 Notice of Privacy Policies and Practices THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND KEEP IT FOR YOUR RECORDS. BY SIGNING THE AUTHORIZATION AND INFORMED CONSENT DOCUMENT, YOU ARE ACKNOWLEDGING YOUR INFORMED CONSENT TO RECEIVING PSYCHOLOGICAL EVALUATION AND TREATMENT FROM ME, NICOLAS WARNER, PSY.D. BEFORE I CAN BEGIN TREATING YOU, YOU ARE REQUIRED TO AGREE TO ALLOW ME TO COLLECT YOUR PERSONAL HEALTH INFORMATION, USE IT, AND DISCLOSE IT AS DESCRIBED BELOW TO CARE FOR YOU PROPERLY. IF YOU DO NOT AGREE AND PROVIDE YOUR CONSENT BY SIGNING THE AUTHORIZATION AND INFORMED CONSENT FORM, I WILL BE UNABLE TO TREAT YOU. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. This may include mental health and personal history information, reasons you came for treatment, diagnoses, treatment plans, progress notes, records I get from other professionals who have treated or evaluated you, psychological test scores and other reports, information about medications you currently take or have taken, billing and insurance information, legal matters, and other forms of health information included in your records that I maintain. Treatment, Payment, and Health Care Operations o Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your primary care physician, psychiatrist, or another psychologist. o Payment is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. o Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, administrative services such as billing, businessrelated matters such as audits, and case management and care coordination. Use applies only to activities within my practice office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside of my practice office such as releasing, transferring, or providing access to information about you to other parties. Authorization is your written permission to disclose confidential personal health information. II. Other Uses and Disclosures Requiring Authorization I may use or disclose your PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. Psychotherapy Notes are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations of your PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures without Authorization I may use or disclose your PHI without your consent or authorization in the following circumstances: Privacy Policies and Practices Page 1 of 2 Revised January 2013

7 Child Abuse If I have reasonable cause to believe a child known to me in my professional capacity may be an abused child or a neglected child, I must report this belief to the appropriate authorities. Adult and Domestic Abuse If I have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, I must report this belief to the appropriate authorities. Serious Threat to Health or Safety If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures I consider necessary to protect you from harm. If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm. Health Oversight Activities I may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions. Judicial and Administrative Proceedings If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law, and I must not release such information without a court order. I can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third-party or where the evaluation is court ordered. You must be informed in advance if this is the case. Worker s Compensation I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault. IV. Patient s Rights and Psychologist s Duties Patient s Rights: Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of your PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.) Right to Inspect and Copy You have the right to inspect and/or obtain a copy of your PHI in my health and billing records used to make decisions about you for as long as your PHI is maintained by me. On your request, I will discuss with you the details of the request for access process. Right to Amend You have the right to request changes of your PHI for as long as your PHI is maintained by me. I have the right to deny your request. On your request, I will discuss with you the details of the amendment process. Right to an Accounting You have the right to receive an accounting (i.e., a list) of disclosures of your PHI that I have made. On your request, I will discuss with you the details of the accounting process. Right to a Paper Copy You have the right to obtain a paper copy of my privacy policy notice upon request, even if you have agreed to receive the notice electronically. Psychologist s Duties: I am required by law to maintain the privacy of your PHI and to provide you with a notice of my legal duties and privacy practices with respect to your PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and practices, the changes will apply to all the PHI I keep and I will notify you of any the changes in writing either in person or by mail. You can find the latest revision of the notice of privacy practices on my practice website ( You can also request a paper copy of the notice from me. V. Questions and Complaints If you have questions about this notice, disagree with a decision I make about access to your records, or have other questions or concerns about your privacy rights, please don t hesitate to ask me for clarifications or further details. You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with me directly and you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. You have specific legal rights under the Privacy Rule. Filing a complaint will not change the care I provide to you in any way and I will never take any action against you for filing a complaint. VI. Effective, Restrictions, and Changes to Privacy Policy This notice is effective as of July 1, Privacy Polices and Practices Page 2 of 2 Revised January 2013