Windstone Behavioral Health
CONFIDENTIAL CLIENT INFORMATION UPDATE-ANNUAL
NAME (First, MI, Last) ______
Street Address: ______
City: ______State: ______Zip: ______
Phone (home/cell/): ______Alt. Phone (home/cell): ______
Date of Birth: ______Email: ______
Emergency Contact (Name): ______
Relationship: ______Phone: ______
Address: ______
INSURANCE INFORMATION
2017 Insurance Plan Name: ______
Insured’s Name : ______
Relationship to Patient: (self / spouse/ child / other )Effective date: ______
Policy No: ______Group No: ______
Employer Group: ______Phone No: ______
Insurance Address: ______
REGARDING YOUR INSURANCE COVERAGE: You are responsible for obtaining prior authorization for treatment from your insurance carrier. We will bill your insurance, however, you are responsible for co-payment and deductibles as set by your benefit plan. Missed appointments are not covered by your insurance and the charges associated with missed appointment are your responsibility (see below.) Co-payment amounts are set by your benefit plan. These payments are due and payable at each appointment. If you are unable to pay your copayment at your scheduled appointment time, we may re-schedule your appointment to a later date. The copayment set by your plan for each visit is $______. For special modalities of treatment not covered by our benefit plan, a written agreement needs to be signed between you and your practitioner. At any time during treatment should your insurance coverage change, you agree to notify the office and your practitioner of any changes prior to your scheduled appointment date to ensure your services are covered at that your practitioner is eligible to render services to you under your new plan. Failure to do so may result in your being fully responsible for payment of the services you receive. At any time during treatment should you become ineligible for insurance coverage, you agree to notify the office and your practitioner prior to receiving services, and you understand that you will be responsible for full payment of services received.
MISSED OR CANCELLED APPOINTMENTS: Scheduled appointment times are reserved especially for you. We require notification at least 24 hours in advance if you must cancel or reschedule an appointment. If an appointment is missed or cancelled less than 24 hours prior to your scheduled appointment time, you may be billed in accordance with the fee schedule and instructions of your benefit plan. Your insurance carrier can not be billed for fees associated with missed or cancelled appointments; you are fully responsible for all such fees. Repeated “no show” appointments may result in our referring you back to your insurance carrier for reassignment to another practitioner
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Patient / Guardian signatureDate
11.30.16