Patient: Date: Address: City ST Zipcode HPhone: Cphone Email Can we leave message? Married Single Employed Student Full/PartTime DOB: Social Security: Emergency Contact: phone# Primary Care Physician Can we contact? 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:
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
FINANCIAL POLICY CANCELLATION/ MISSED APPOINTMENT POLICY Please understand the following with regard to your appointments and our financial policy: We require 24 hour notice in the event you need to reschedule your appointment. Testing appointments will require 48 hours notice for rescheduling. If you will be more than 15 minutes late for your scheduled appointment, the therapist will be unable to see you and you will be charged the no show fee. Without 24 hours notice (48 hours for testing) of a rescheduled appointment, you will be charged $50.00 for your missed appointment. Your payment of $50.00 is due before your next scheduled appointment. If this payment is not received before your next appointment, your appointment will be cancelled. Payment of your deductible and/or copay are expected with each visit. If collection actions are necessary, you will be responsible for all costs incurred due to this action, which is an additional 40% of balance due for collection agency fees, and all charges involved for attorney s fees, court cost, etc. I have read the above information and agree to be bound by its terms. Signature Date: Witness Date
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 #
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 #
SIGNATURE ON FILE Please check all 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: