Referred By: Can we contact?
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- Prosper Neal
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1 Patient: Date: Address: City ST Zipcode HPhone: WPhone: Cphone Can we leave message? Married Single Employed Student Full/Partime DOB: Social Security: Emergency Contact: phone# Is your condition related to? MVA If yes, DOA State Referred By: Can we contact? Primary Insurance Phone: Address: Insured InsuredDOB InsuredEmployer Insured ID# Group # Secondary Insurance Phone: Address: Insured InsuredDOB InsuredEmployer Insured ID# Group # ASSIGNMENT OF INSURANCE BENEFITS: I hereby do authorize Shore Neuropsychology and Behavioral Health, to provide or collect from my insurance company information needed to process claims and or determine benefits. I hereby do authorize payment directly to physician/provider. I am responsible for all non-covered services rendered by the physician/provider. X Date:
2 CONFIDENTIALITY POLICY The relationship between patient and therapist is a confidential one. Information will not be released from this office regarding your therapy without your expressed permission, with the exception of emergency or requirement by law, as outlined in the HIPPA policies. If you wish information released to anyone, it will be necessary for you to complete a release of information form, stipulating the profession to whom the information is to be sent. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Shore Neuropsychology & Behavioral Health, to provide/request Physician(s)Name: with information regarding my evaluation and treatment. Signed Date Witness Date I hereby authorize Shore Neuropsychology & Behavioral Health, to provide/request Attorney Name: with information regarding my evaluation and treatment. Signed Date Witness Date A reproduction/scan of this authorization shall be considered as effective and valid as the original. Signature: Date Name of patient: Soc Sec #
3 CANCELLATION/ MISSED APPOINTMENT POLICY We understand there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting the much needed treatment. We request you please give us 24-notice in the event you need to reschedule your appointment. As a courtesy we make reminder calls the days prior to your schedule appointment. Unless cancelled at least 24 hours in advance, our policy is to charge $50.00 for missed appointments. I have read the Cancellation/ Missed Appointment Policy and agree to be bound by its terms Signature Date: Witness Date
4 NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT My signature below attests that I am in receipt of a copy of the HIPPA Privacy Regulations. I have received this practice s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice s legal duties with respect to my protected health information. I understand this practice reserves the right to change the terms of its Notice to Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice s current Notice of Privacy Practices on request. Name Signature Date Please note if you do not wish to be contacted at any specific location or if you do not wish a message left at any specific phone number. Location Number Special Instructions The above named individual refused to sign. Custodian of Privacy Signature: Date
5 SIGNATURE ON FILE Please check all that apply. I authorize release of information to all of my insurance companies. I authorize Shore Neuropsychology Behavioral Health to act as my agent in helping me obtain payment from my insurance companies. I authorize payment direct to Shore Neuropsychology & Behavioral Health I permit a scanned copy of this authorization to be used in place of the original. I understand that I am responsible for my bill. Name: (Please Print) Social Security: Signature (Signature of Parent or Guardian if patient is a minor) Date: Witness: Date:
6 CONFIDENTIALITY POLICY The relationship between patient and therapist is a confidential one. Information will not be released from this office regarding your therapy without your expressed permission, with the exception of emergency or requirement by law, as outlined in the HIPPA policies. If you wish information released to anyone, it will be necessary for you to complete a release of information form, stipulating the profession to whom the information is to be sent. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Shore Neuropsychology & Behavioral Health to provide/request: 1.Name Address 2.Name Address 3.Name Address With the following health information: please send all applicable records. A scanned copy of this authorization shall be considered as effective and valid as the original. Signature: Date Name of patient: Soc Sec #
Patient: Date: Address: City ST Zipcode. HPhone: Cphone . Can we leave message? Married Single Employed Student Full/PartTime
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