Pediatric Registration Form

Patient Name: / Date:
Date of Birth: / Age: / Social Security Number:
Parent or Legal Guardian 1: / Relationship:
Address:
Preferred Phone: (Please circle) / May we contact? / May we leave a detailed message? / Please only leave a message to return call.
Cell: / Y N / Y N / Y N
Work: / Y N / Y N / Y N
Home: / Y N / Y N / Y N
Text: / Y N / Y N / Y N
_____(Initial) Text Messaging: I understand that texting for appointments is provided for my convenience, however, it is not HIPPA compliant. Any text messages sent while encrypted on my providers device, may still accessed by the phone service provider. I will not hold my provider legally liable for any information provided in a text.
Parent or Legal Guardian 1: / Relationship:
Address:
Preferred Phone: (Please circle) / May we contact? / May we leave a detailed message? / Please only leave a message to return call.
Cell: / Y N / Y N / Y N
Work: / Y N / Y N / Y N
Home: / Y N / Y N / Y N
Text: / Y N / Y N / Y N
_____(Initial) Text Messaging: I understand that texting for appointments is provided for my convenience, however, it is not HIPPA compliant. Any text messages sent while encrypted on my providers device, may still accessed by the phone service provider. I will not hold my provider legally liable for any information provided in a text.

CONSENT FOR MENTAL HEALTH SERVICES (Counseling)

______(Initial) I hereby consent to engage one in diagnostic/mental health services with Laura Lyn Zane, PLLC.

PATIENT RIGHTS AND COMPLAINTS PROCESS

______(Initial) I understand that I have a right to refuse treatment at any time. Unless otherwise agreed to in writing in such cases where HIPPAA does not apply (e.g. Worker’s compensation, litigation), I have a right to review my records, diagnoses and treatment plan. I understand if I feel that my rights have been violated, it is my right to file a complaint with the State of Florida (see posted Consumer Assistance Notice).

NO SHOW AND CANCELLATION POLICY

THE FEE for a no-show or cancellation less than 3 days in advance is $100.00 for a psychotherapy appointment

The fee will be waived if you are able to reschedule your appointment within the same week, if your provider has availability. The fee may be waived upon discussion with your provider.

You have made a commitment for that day and time and it cannot be easily filled, even with several days’ notice. If there is a serious illness or emergency event that would prevent you from coming to your appointment, you must contact us as soon as possible. Simply leaving a message on the phone cancelling your appointment will not relieve you of your financial responsibility. Note that insurance companies cannot be legally billed for a no-show or cancellation.

______

Print Patient Name Signature of Patient Date

Subpoenas:

______(Initial) I understand that if the client or guardian subpoenas the therapist for court, the charge is $250.00 an hour, including drive time. Due to the fact the therapist needs to at least partially clear their schedule in order to make sure they are available for court, there is a 2 hour minimum. If for some reason the subpoena is released, a 7 day notice is required, otherwise the 2 hour minimum applies.

Telephone Calls

______(Initial) Telephone calls over 10 minutes will be considered a session and will be charged accordingly. This may or may not be covered by you insurance.

Appointment Reminders

As a courtesy we can send you appointment reminders via your e-mail address or text. Provide us with your email address if you would like this service.

E-Mail Address______

_____ (Initial) I authorize Laura Lyn Zane PLLC to send me via email, confirmation of my appointments

_____ (Initial) I authorize Laura Lyn Zane to send via text, confirmation of my appointments

_____ (Initial) I do not want reminders of my appointments.

______/___/___

Print Patient Name Signature of Patient/Guardian Date

Release of Clinical Information

Information cannot be released without consent except under the following circumstances which may be required by law, reporting to the state of Florida or otherwise releasing information to another party without consent:

1.  If there is imminent danger of self-neglect or self-harm or imminent danger to another individual.

2.  If there is suspicion of child abuse or neglect.

3.  If there is suspicion of elder abuse or neglect.

4.  If there is suspicion of abuse or neglect of a disabled individual.

5.  If there is suspicion of an inappropriate sexual relationship with a healthcare provider.

6.  If there is legal action brought involving mental health damages.

7.  If there is a court order signed by a judge.

8.  If evaluation or treatment is provided with forensic/legal or Workman’s Compensation involvement where the client is another individual or agency with whom information may be shared without your consent.

Initial:______

Insurance Information

DO NOT COMPLETE IF YOU PROVIDED A COPY OF YOUR INSURANCE CARDS OR IF WE WILL NOT BE BILLING YOUR INSURANCE COMPANY

Primary Insurance Carrier:______

Policy/Plan Number: ______

Group Number:______

INSURANCE PRE-CERTIFICATION

______(Initial) I hereby expressly understand that I am personally responsible for any required notification to my insurance company to obtain authorization before service is rendered.

FINANCIAL AGREEMENT

_____(Initial) I understand that I am responsible for the charges not covered by insurance which are allowable by contract and by law. I hereby guarantee prompt payment of all charges incurred for services rendered not covered by insurance carriers or others. Payment will be made of any balance within 30 days of billing. If payment is not received within 30 days, finance charges may begin to accrue at the maximum rate allowed by law. I agree that my credit card can be billed for any outstanding balance. If payment is not received within 30 days of the date such a balance is due, the bill may be turned over to an attorney or a collection agency, at which time the undersigned shall be liable for attorney’s fees and/or collection agency fees and expenses.

______(Initial) I understand if payment and/or payment arrangements are not made within 30 days of service, my counselor may terminate services and refer me to a more affordable provider.

ASSIGNMENT OF BENEFITS

_____(Initial) If I am entitled to mental health benefits arising out of any insurance policy or from any person or organization who is or may become liable to provide me with such benefits, I hereby assign and authorize payment of such benefits for mental health services to which I am entitled to Laura Lyn Zane, PLLC for services rendered to me.

I authorize submission of necessary claims of payment. I authorize any holder of medical, mental health, and/or financial information about me to release to the Health Care Financing administration any information needed for proper reimbursement.

RELEASE OF INFORMATION FOR PAYMENT

_____(Initial) I expressly authorize any agent of Laura Lyn PLLC to release all or part of my mental health record by telephone, facsimile transmission, by e-mail or in writing when required by law or government regulation, or as a condition for payment of charges for insurance carriers or other reimbursers or utilization review bodies. I give authorize Laura Lyn Zane PLLC, it’s agents, servants and employees are hereby released from any and all liability that may arise from the release of such information.

______/___/___

Print Patient Name Signature of Patient/Guardian Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE TO PRIVACY PRACTICES

Please sign and print your name and date on this acknowledgement form, that you were given a copy of our Notice to Privacy Practices for your review:

______/___/___

Print Client Name Signature of Client/Guardian Date