PREFERRED METHOD OF COMMUNICATION
Please provide phone and email and indicate by checking beside preferred method
Primary Insurance
Secondary Insurance
Emergency Contact
If Psych Riverwalk DOES participate with your insurance pian, we will ask you to pay any co-payment, deductible or
co-insurance amounts at the time of your service. A claim will be submitted to your insurance company.
If Psych Riverwalk DOES NOT participate with your insurance plan, we will ask you to pay in full at the time of service and as a courtesy we will help you submit a claim to your insurance company.
** SPECIAL NOTE REGARDING MENTAL HEALTH DISABILITY AND WORKERS' COMPENSATION EVALUATION"*
* We DO NOT complete forms for Disability Application/Continuation or Workman's Compensation Evaluation or Claims.
• We DO NOT fill out forms for Psychiatric Opinion Request for Legal Counsel.
I have read and understand 4c policy regarding Mental Health Disability and Workman's Compensation Evaluation.
HIPAA POLICY & PATIENT CONSENT FORM
The Health insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirement officially began on April 14, 2003. Many of the policies have been our practice for years. This is an abbreviated version; however, the complete text is available in our offices or on the U.S. Department of Health and Human Service website: www.hhs.gov
HIPAA states that there are rules and restrictions who may see or be notified of your Protected Health information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with our office medicals services.
Your information will be kept confidential up to 12 months, except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers if desired, laboratories and health insurance payers as
is necessary and appropriate for your care.
Our Electronic Medical Records (EMR) is secure and personal information is encrypted to insure confidentiality. General information which does not include any client identifiers may be used in retrospective studies. However, studies requiring any personal identifiers will require your approval and consent.
It is policy of this office to remind clients of their appointment. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to the office policy and new technology that you might find valuable or informative.
We agree to provide clients access to their records in accordance with state and federal laws. You understand and agree to inspection of the office and review of document which may include PHI by government agencies or insurance payers in normal performance of their duties.
We may change, add, delete or modify any of these provisions to better serve the needs of the practice and the clients. You have the right to request restrictions in the use of your protected health information as the law permits. Your confidential information will not be sold for any reason.
Your signature will indicate that you have read the HIPAA information and consent to the guidelines set forth
in the Act.
Authorization for Release of Protected Health Information (HIPAA Compliant)
hereby authorize the above - named person or entity, its
agents, employees and associates (the "Disclosing Party"), to release the protected health information described below
to/from, Its agents, employees and associates for up to 12 months.
3. The protected health information is to be disclosed for the following purposes.
4. I understated that I may revoke this authorization in writing at any time by sending a written revocation to the Disciosing Party's
address set forth above, provided that this authorization cannot be revoked as to protected health information that has previously been
released in reliance on this document.
5. I understand that a refusal to sign this authorization will not result in a denial of health care by the Disclosing Party of any other
health care provider.
6. I understand that once the protected health information is disclosed, it may be re-disclosed individuals or organization that are not
subject to the federal privacy regulations and would no longer be protected by those regulations.
7. I understand that I am entitled to a cooy of this authorization.
8. I acknowledge the Disclosing Party and its agents, employees and associates are released from legal responsibility or llability 101
release of the above- described protected health information to the extent indicated and specifically authorization herein.
OUR FINANCIAL & CANCELLATION POLICY
We are dedicated to providing the best possible care for you and we want you to completely understand our financial
policies.
1. The patient agrees to pay the patient responsibility at the time of service.
2. We accept Cash, Checks, Visa, Mastercard, Discover and American Express. We also work with Advance Care Card, please ask staff for details.
3. Check Return Fee is $25.00.
4. Patient is responsible for notifying Psych Riverwalk of any changes in insurance. If fees accrue due to an unreported change
in insurance, the patient is responsible for any non-covered service fees.
I have read and understand Psych Riverwalk Financial Policy and I agree to be bound by the terms above.
l agree to the following policy:
1. That I will give your office a 24-hour notice in event that I need to reschedule my appointment. This will make the appointment time available to someone else. Our scheduling number is:
2. As a new patient, if I miss an appointment and do not contact the office with at least 24-hour notice, the office will consider this to be a No-Show appointment and a $100.00 fee will be assessed to me.
3. As a follow-up patient, if I miss and appointment and do not contact the office with at least 24-hour prior notice, the office will consider this to be a No-Show appointment and a $100.00 fee will be assessed to me.
4. I I am late for an appointment, I will be seen if time permits. Otherwise, I may need to reschedule my appointment and may be considered as a No-Show.
5. As a courtesy, when time allows, we make reminder calls for appointments. If I do not receive a reminder call or message, the cancellation policy will remain in effect.
I hereby authorize Psych Riverwalk to deduct Check Return Fees, Non-Covered Service Fees and No-Show Fees.
Controlled Substance(s) Agreement
Controlled substance medications (i.e. Benzodiazepines, opioids, amphetamines) are very useful, but have a high potential
for misuse and are, therefore, ciosely controlled by local, state, and federal governmentis). As a patient of Psych Riverwalk, you
agree and understand the following (initial each section):
I have been fully informed of the above treatment agreement points and have a full understanding of my duties as a patient of Psych Riverwalk in regards to the controlled substances my physician is prescribing
Informed Consent for Telemedicine Services
Introduction
Telemedicine in involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or aducation, and may include any of the following:
• Patient medical records
• Medical images
• Live two-way audio and video or solely audio
• Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data
and to ensure tis integrity against international of unintentional corruption.
Expected Benefits:
• Improved access to medical care by enabling a patient to remain in his her Psych Riverwalk provider's office (or at a remote site) while the physician obtains consults from healthcare practitioners at
distant/other sites.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant socialist
Possible Risks.:
As with any medical procedure, there are potential risks associated with the use of telemedicine
These risks include, but may not be limited to
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the
equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse
reactions or other judgment errors;
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information
also apply to telemedicine, and that no information obtained in the use of telemedicine which
identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that 1 have the right to inspect all information obtained and recorded in the
course of a telemedicine interaction and may receive copies of this information for a reasonable fee.
4.|I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My Psych Riverwalk provider has explained the
alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my psychiatrist of electronic interactions
regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my
care, but that no results can be guaranteed or assured.
Patient Consent to the Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have
discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.I hereby authorize Success 7MS to use telemedicine during the course of my diagnosis and treatment.
NOTICE OF NON COVERAGE
Note: if your healthcare insurance does not reimburse for psychiatric evaluation management
therapy below you will be required to cover the fees your insurance does not cover.
90792: psychiatric diagnostic evaluation----$300
99213: psychiatric follow up low to moderate intensity-----$100
99212: psychiatric follow up low intensity-----$100
What you need to do now:
-read this notice so you can make an informed decision about your care.
-Ask us any questions that you may have to atter you finish reading it.
I want a psychiatric evaluation and medication management as listed above. I understand that I will be responsible for any out of pocket expenses that may not be covered by my insurance, such as
copays, co insurance, and deductibles. I understand that i may be responsible for the full posted amount.
