Affiliates in Behavioral Health LLC

Patient Information

Insurance Policy Holder

Insurance Information

Guarantor Information/Insurance Policy Holder (Financially responsible adult who will sign below)

In case of emergency who should we contact?

By signing below I acknowledge that all information provided above is true and accurate. I understand that my insurance information is being verified and that l may be billed as self-pay if I fail to provide accurate insurance information. I understand that returned checks will be subject to fees. I understand that I will be charged for appointments canceled with less than 24 hours notice and for appointments that I fail to cancel and/or show up for. I understand that any accounts placed for collections will incur a late fee. I acknowledge that I have been informed of my rights of privacy and I am authorizing treatment.

Health and Wellness History

How Much Of The Following Does The Patient Consume Daily?

Patient Rights and HIPPA

As a patient being treated in our practice, you have a right to:

• Receive respectful treatment that will be helpful to you
• Receive a particular type of treatment or end treatment without obligation or harassment
• A safe environment, free from abuse
• Report unethical or illegal behavior by a clinician
• Ask questions about your therapy
• Request and receive full information about the clinician’s credentials
• Have written information about fees, methods of payment, insurance reimbursement, and cancellation policies before beginning treatment
• Refuse electronic recording, but may request it if you wish
• Know the limits of confidentiality and the circumstances under which a clinician is legally required to disclose information to others
• Request a transfer of a copy of your file to any clinician or agency you choose
• Receive a second opinion at any time about your treatment
• Request that the clinician inform you of your progress
• Receive a copy of this form
• Have your privacy respected at all times.

Our Notice of Privacy Practices describes potential uses and disclosures of your health information by our practice and outlines your behavioral health privacy rights. Please read it carefully. For questions, please contact our Privacy Officer at (216) 520-5969.

By signing below you are indicating that you have read and am aware of your patient and privacy rights and that you have received a copy of Affiliates‘ Notice of Privacy Policies.

Financial Responsibility

I understand that Affiliates in Behavioral Health LLC expects payment in full at the time of the appointment unless preauthorization for treatment has been obtained before the appointment. If the patient is my child, I understand that the parent accompanying the child to the appointment is responsible for payment at the time of service. I understand that my insurance company will only pay for services that are medically necessary and for which I have obtained preauthorization. Since insurance companies do not pay for missed appointments, I understand that I will be personally liable for payment of any missed appointments not canceled with at least 24 hours notice. Accounts overdue for sixty days may be turned over to an external collection service. In the event of non-payment of charges, I agree to pay all costs of collection, including reasonable attorney fees. If for any reason the insurance company denies payment for the treatment rendered, I understand that I am personally and fully responsible for payment of these services. I will also be responsible for deductibles, copayments, collection fees or missed appointment fees. I authorize Affiliates in Behavioral Health LLC to release all information needed to secure payment of my or my child’s account. I understand that Affiliates in Behavioral Health LLC will cooperate with my insurance company to assure that my insurance company helps to pay for treatment. However, I understand that I am ultimately responsible for obtaining authorization for care and for ensuring that the insurance company is making timely payments.

CONSENT FOR TREATMENT and COORDINATION OF CARE

I give permission for clinicians at Affiliates in Behavioral Health LLC to evaluate, coordinate and treat me or my child (for whom I am legal custodian). I further authorize any tests, procedures and medication as deemed necessary and mutually agreed to by me. To facilitate coordination of care, I authorize the release of medically necessary information to other treating clinicians at Affiliates in Behavioral Health LLC as well as to the patient’s.

MEDICARE PATIENTS ONLY

I request that payment of authorize Medicare benefits be made on my behalf to Affiliates in Behavioral Health LLC for any services furnished to my children or me. I authorize any holder of medical information about me to release my medical information to the Center for Medicare and Medicaid Services or its agents in order to determine benefits payable for related services. I understand my signature requests that payments be made and authorizes release of medical information necessary to pay the claim. If the appropriate items of the HCFA-1500 claim form are completed, my signature authorizes release of information to the insurer or agency shown. In Medicare assigned cases, I will be responsible for the amount remaining between Medicare’s payment and the Medicare allowed charge, any deductible, co—insurance, copayments and non—covered services. Co-insurance, copayments and deductibles are based upon the charge determination of my particular Medicare carrier.

Office Policies

Below is a list of our standard office policies Please be sure to read through and then sign and date at the bottom. This will acknowledge that you have read and understand our policies.

• There will be a charge for late cancellations (cancellations not made with more than a 24 hour notice) and for no-shows. Insurance will not reimbursefor any missed appointments or late cancellations.
• The missed appointment/late-cancel fees are as follows:
  o $60.00 for all clinicians
  o $50.00 for the psychiatrists
  o $150.00 for initial visit for the psychiatrists
• Should you late cancel or no-show for 2 appointments it is the clinicians/psychiatrists discretion to discontinue your treatment with our office. Should that happen, you will be given at least 3 references of other clinics that you could contact.
• There is a 48 hour turn around time on all medication requests. Please be advised that our psychiatrists are not here everyday and we need to get in contact with them to advise them of the request.
• There is a 48-72 hour turn around time on all medical records requests. Please be advised that a current release of information form must be signed and on file for any records to be released.
• Copays are expected to be paid for at the time ofyour visit.
• Please be sure to advise the office staff of any changes made to your insurance coverage or address. Ifthere has been a change in your insurance, please notify us immediately so that we can process your claims correctly. Also, please be sure to bring in or fax [(216) 520-5098] us the updated insurance card (front and back).