CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Scial Security Number: Male: Female: Hme Address: (Street / RR Bx # / Apt. #) (City/State) (Zip) Preferred Cntact Number (this number will be used fr appintment reminders): Hme Cell Wrk Hme Phne: Wrk Phne: (Ext.) Family Physician: Pharmacy: Cell Phne: Emplyer: Phne: Phne: I give my cnsent t CRG s prviders and/r staff t cntact the fllwing persn in the event f an emergency: Emergency Cntact: Preferred Cntact Number: Relatinship t Patient: Preferred Cntact: Hme Cell Wrk IF PATIENT IS A MINOR: Parent s Name: Bilgical Mther/Father Step-Mther/Father Legal Guardian Adptive Mther/Father Birth : Scial Security Number: Address (if different frm patient s): (Street / RR Bx # / Apt. #) (City/State) (Zip) Parent s Emplyer: Parent s Occupatin: Parent s Preferred Cntact Number: Parent s Name: Bilgical Mther/Father Step-Mther/Father Legal Guardian Adptive Mther/Father Birth : Preferred Cntact: Hme Cell Wrk Scial Security Number: Address (if different frm patient s): (Street / RR Bx # / Apt. #) (City/State) (Zip) Parent s Emplyer: Parent s Occupatin: Parent s Preferred Cntact Number: Preferred Cntact: Hme Cell Wrk Page 1
PRIMARY INSURANCE Primary Ins. C. Name: Ins. C. Phne: Plicy Hlder s ID#: Grup #: Plicy Hlder s Emplyer: Effective f Cverage: Plicy Hlder s Name: Plicy Hlder s DOB: Plicy Hlder s Address: (Street/ RR Bx# / Apt. #) (City/State) (Zip) Relatinship t patient: Plicy Hlder SSN: Verified Benefits: Yes N Authrizatin Required: Yes N *Please cntact CRG s billing department at (317) 575-9111 ptin #7 if yu need help btaining preauthrizatin. BEHAVIORAL HEALTH Wh handles yur Behaviral Health (BH) cverage: Primary Insurance Carrier Separate BH Carrier *If yu answered Primary Insurance Carrier yu d nt need t cmplete the behaviral health prtin f the frm. Separate BH Carrier: BH Carrier Phne: BH ID#: BH Grup #: Effective f Cverage: Plicy Hlder s Name: Plicy Hlder s DOB: Plicy Hlder s Address: (Street/ RR Bx# / Apt. #) (City/State) (Zip) Relatinship t patient: Plicy Hlder SSN: Verified Benefits: Yes N Authrizatin Required: Yes N *Please cntact CRG s billing department at (317) 575-9111 ptin #7 if yu need help btaining preauthrizatin. Page 2 SECONDARY INSURANCE Please cmplete ONLY IF yur secndary insurance is SAGAMORE: Plicy Hlder s ID#: Grup #: Plicy Hlder s Emplyer: Effective f Cverage: Plicy Hlder s Name: Plicy Hlder s DOB: Plicy Hlder s Address: (Street/ RR Bx# / Apt. #) (City/State) (Zip) Relatinship t patient: Plicy Hlder SSN: Verified Benefits: Yes N Authrizatin Required: Yes N
CONSENT TO TREAT I request and authrize Children s Resurce Grup (hereinafter cllectively referred t as CRG ) and their respective agents and emplyees wh may attend me during my treatment t perfrm rutine test and prcedures and t prvide certain services as prescribed fr my health and well-being in accrdance with applicable laws and regulatins. I acknwledge that n representatins, warranties, r guarantees as t results f cures have been made t me by CRG, nr have I relied upn any such representatins, warranties, r guarantees. Patient Signature r Legal Guardian Signature if patient is a minr If signed by Legal Guardian, state relatinship t patient: ACKNOWLEDGEMENT By signing belw, I acknwledge that I have received a cpy f the CRG Patient Admissin Packet, which includes but is nt limited t the Ntice f Privacy Practices ( Ntice ). I understand that I may btain a written cpy f this Ntice at any time upn request r via the website at www.childrensresurcegrup.cm. Patient Signature r Legal Guardian Signature if patient is a minr EMAIL COMMUNICATIONS CRG recgnizes that cmmunicatin between patients and ur frnt ffice staff can be helpful in many circumstances. By cmpleting this frm, I give my cnsent fr CRG t send electrnic cmmunicatins t the email address listed belw. Patient/Parent s Name: Self Bilgical Mther/Father Step-Mther/Father Legal Guardian Adptive Mther/Father Email Address: Parent s Name: Bilgical Mther/Father Step-Mther/Father Legal Guardian Adptive Mther/Father Email Address: MEDICAL PHOTOGRAPHY I hereby cnsent t the taking f a phtgraph f me by CRG. I understand that my phtgraph may be used t assist with identificatin and treatment. Other than fr treatment and identificatin reasns, images that identify me will nt be released t any utside entity unless requested by me r my legal representative. Patient Signature r Legal Guardian Signature if patient is a minr Page 3
FINANCIAL AGREEMENT (REQUIRED) By signing belw, I acknwledge that I have received a cpy f CRG s Financial Plicy, pages 5 and 6 f the registratin packet, and hereby agree t cmply with these requirements. Signature n CRG s Financial Agreement is required prir t yur appintment. Patient Name Respnsible Party (please print) Relatinship t patient DOB Respnsible Party s SS# Respnsible Party s DOB Address (Street / RR Bx#) (City/State) (Zip) Hme Phne Signature f Respnsible Party Wrk Phne *A Release f Infrmatin may be required if the Respnsible Party is smene ther than client* CREDIT CARD AUTHORIZATION (OPTIONAL) I authrize CRG t charge the credit card prvided belw fr services rendered, including deductibles and c-pays. This authrity expressly authrizes any and all future charges and is t remain in full frce and effect until CRG has received a thirty (30) day written ntificatin frm the undersigned f any mdificatins t this credit card authrizatin. I als agree nt t dispute any charges t the credit card after sixty (60) days frm the date f the charge. Depending n hw yur card is prcessed, CRG may have the ability t email yur receipt. Please include yur email address belw fr yur receipt t be emailed if this ptin becmes available t us. By signing this Authrizatin, I certify that all infrmatin prvided belw is true and accurate. Credit Card # Expiratin V-Cde Cardhlder Zip Cde Please check ne: Debit Credit Health Savings Accunt Cardhlder Name Cardhlder Email Address Page 4 Cardhlder Signature
Page 5 2019 CRG FINANCIAL POLICY Payment in Full is Required at Time f Service. CRG accepts payment by cash, check, credit card r mney rder. As a curtesy t ur clients, the respnsible party may leave a credit card n file t be autmatically run after a service has been prvided. The fllwing are the nly exceptins t payment in full at time f service: Sagamre r Multiplan* is listed as prvider netwrk fr yur mental/behaviral health insurance benefits (see Prvider Netwrks belw fr mre details). *Beginning 02/01/2019, Multiplan will n lnger be a Cntracted Prvider Netwrk, therefre, payment in full fr all Multiplan clients will be required at time f service. Payment arrangements have been made with CRG s billing department at least 24 hurs prir t the appintment (see Payment Arrangements belw fr mre details). Payment arrangements fr Psychlgical Evaluatins have been made in advance with the billing department (see ur Evaluatins Plicy n the CRG website r btain a cpy at the frnt ffice). Prvider Netwrks Insurance Cmpanies CRG is nt cntracted with insurance cmpanies. Cntracted Prvider Netwrks & Prviders CRG is cntracted with Sagamre Health Netwrk and Multiplan* t prvide a negtiated rate fr cvered mental health services. *Beginning 02/01/2019, Multiplan will n lnger be a Cntracted Prvider Netwrk, therefre, payment in full fr all Multiplan clients will be required at time f service. Nt all services prvided by CRG are cvered mental health services. It is every client s respnsibility t verify their wn insurance cverage and understand what is and is nt a cvered service. Any c-payment amunts and deductibles may be cllected at the time f service. The respnsible party will be bligated fr the remainder f the (billed charge r fee) fr all cvered services after 90 days if the (billed charge r fee) has nt prcessed by the insurance carrier. The respnsible party will be bligated fr the full amunt f any nn-cvered services at the time the service is prvided. It is the respnsibility f the client t check benefits with his/her insurance cmpany and understand what is and is nt cnsidered a cvered service. Nn-Cntracted Prvider Netwrks, Prviders, & Self-Pay Clients Payment is required at the time f service fr all insurance netwrks ther than thse listed abve. Medicare, Medicaid, Tri-Care, ICHIA CRG is nt cntracted and nt able t file insurance claims t Medicare, Medicaid, Tri-Care r ICHIA. Therefre, payment is required at time f service. The client r legal guardian will be required t sign a waiver dcumenting their understanding f the abve item. Upn request, CRG can prvide encunter frms fr the client t self-file t ne f the abve insurance cmpanies. Filing Claims t Insurance The insurance plicy is a cntract between the insured and the insurance carrier. It is the respnsibility f the insured persn t verify their mental health benefits with their insurance carrier. CRG strngly encurages verifying be dne prir t yur initial appintment r after there is a change in yur insurance. Failure t prvide cmplete insurance infrmatin and a cpy f yur insurance card may result in patient respnsibility fr the entire bill. Failure t prvide new insurance infrmatin within 30 days f the effective date f cverage will require yu t self-file any prir claims t yur new insurance carrier. Primary Insurance CRG will rutinely file insurance claims with a client s primary carrier fr services fr bth cntracted prvider netwrks and, as a curtesy, fr nn-cntracted prvider netwrks. Pre-authrizatin r pre-certificatin requirements by the insurance cmpany are the respnsibility f the member and must be put in place prir t the appintment. CRG s billing department will be able t assist with any questins upn request. Imprtant: In rder fr CRG t file insurance claims fr drug and/r alchl related services, a separate authrizatin frm must be cmpleted fr the insurance carrier and a separate release fr parents f minr children. Patients ages 14
and lder are required by law t sign the authrizatin frm/release themselves. Please btain this frm the CRG website r frm the frnt ffice. Secndary Insurance CRG will nt file t secndary insurance carriers unless the secndary insurance is ne f ur cntracted prvider netwrks. It is the respnsibility f the insured t supply t CRG an Explanatin f Benefits (EOB) frm the primary insurance carrier within 30 days when we are an ut f netwrk prvider. Failure t supply the EOB s may result in patient respnsibility fr the entire bill. Insurance Appeals Due t insurance cmpany requirements, filing appeals are the respnsibility f the insured. CRG will supply dcumentatin requested frm the insured t assist with appeals within 72 business hurs f the request. Payment Arrangements Payment arrangements will nt be accepted fr initial visits. The respnsible party is required t sign a prmissry nte. This needs t be n file at least 24 hurs prir t the appintment. The respnsible party is required t maintain financial cmpliance with the terms stated in the prmissry nte. If financial cmpliance is nt maintained, the accunt will be turned ver t ur cllectin agency. Outstanding Balances Unpaid balances remain the respnsibility f the individual wh signed the financial agreement n the registratin frm. Accunt balances due after 60 days frm the date f service will prmpt the accunt t be reviewed fr cllectins. Once an accunt has been turned ver t ur cllectin agency, the respnsible party must reslve the unpaid balances with the agency. Financial nncmpliance culd result in the client receiving a 30-day discharge ntice frm CRG. When the cllectin agency is engaged n the accunt, the respnsible party will be liable fr any interest that may be added at the current legal rate and fr any attrney fees required t cllect fr services. Missed Appintments and Late Cancellatins Missed appintments r cancellatins made less than 24 hurs in advance f the scheduled appintment will be charged t the patient s accunt at 100% f the fee f the missed appintment. After the first missed r late cancelled Intake Appintment, a valid credit card is required t be put n file prir t scheduling the secnd intake appintment. *Yur credit card will nt be charged unless the secnd Intake Appintment is missed r cancelled less than 24 hurs f the scheduled appintment. Payment in advance will be required t hld an appintment n a prvider s schedule after the 2 nd late cancelled r missed intake r testing appintment. Returned Checks Checks returned fr insufficient funds will result in a $35 charge t the client s accunt. If CRG receives tw checks fr insufficient funds frm the same respnsible party, that respnsible party will be required t make all future payments by cash, credit card r mney rder. Pst-d Checks Pst-dated checks will nt be accepted. Minrs & Patients with Divrced Parents Cncerning minr children, the individual bringing the child in will be respnsible fr payment at the time f service. Financially respnsible parties wh are unable t attend the appintment are encuraged t put a credit card n file s that payment can be cllected at time f service. Als, financially respnsible parties can call the day f the appintment t make a payment. Miscellaneus Services and Fees CRG is eligible t charge the state-accepted fees fr cpying recrds, letter writing, filling ut extensive frms, legal services, r ther miscellaneus prvider services. ***Clients will be required t update and sign CRG s Financial Agreement annually*** Page 6