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Dr. REBEKAH WAHKINNEY, Ph.D.
Licensed Psychologist
510 24th Avenue, SW, Norman, OK., 73069. 405-329-7923: Fax: 405-329-8815
CLIENT INFORMATION
Today’s Date______Person or Office Who Referred You ______
Client’s Full Name ______
Date of Birth ______Age ______Gender M / F SSN # ______
Marital Status Single / Married / Other Spouse's Name ______
Patient’s Employment Status Employed / Full-Time Student / Part-Time Student / Other
Street Address ______
City / State / Zip ______
Mailing Address (if different from above) ______
City / State / Zip ______
CONTACT INFORMATION
Please list your information in the spaces below as to how we may reach you regarding appointment times, billing, and payment.
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Cell Voicemail or Text ______
Home Voicemail ______
Work Voicemail ______
Spouse / Significant Other ______
Email Address ______
Co – Worker (appt. info only) ______
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You can receive an automated appointment reminder to your email address, your cell phone (via a text message), or your home phone (via a computer generated voice message) the day before your scheduled appointments.
Your cell phone carrier (check only one):
ACS / Metro PCS / T-MobileAlltel / Nextel / US Cellular
AT&T / Quest / Verizon
Boost Mobile / Sprint / Virgin Mobile
Cricket / Suncom / VoiceStream
Place a check mark below indicating by which method you would like to receive an automated appointment reminder.
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_____ Via a text message on my cell phone (normal text message rates will apply – only compatible with companies listed above)
_____ Via an email message to the address listed above
_____ Via an automated telephone message to my home phone
_____ None of the above. I’ll remember my appointments on my own.Missed appointment fees will still apply.
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______
SIGNIFICANT OTHER: Name ______
Relationship Status ______Employer ______
EMERGENCY CONTACT ______Relationship ______Phone ______
Address / City / State / Zip ______
RESPONSIBLE PARTY (If NOT client: Parent, Guardian, Spouse. Person agreeing to fee and consenting for services.)
Name ______Relationship ______Phone ______
Date of Birth ______Age ______Gender M / F SSN # ______
Street Address ______
City / State / Zip ______
PAYMENT INFORMATION If private pay, provide alternative payment arrangement ______
Primary InsurancePolicy Holder’s Full Name ______
Date of Birth ______SSN # ______Phone # ______
Street Address ______
City / State / Zip ______
Employer ______Insurance Plan Name ______
Subscriber ID# ______Group # ______
PreCert required? Yes / No PreCert by Whom ______
Authorization Number: ______Start Date ______End Date ______
Secondary InsurancePolicy Holder’s Full Name ______
Date of Birth ______SSN # ______Phone # ______
Street Address ______
City / State / Zip ______
Employer ______Insurance Plan Name ______
Subscriber ID# ______Group # ______
PreCert required? Yes / No PreCert by Whom ______Authorization Number: ______Start Date ______End Date ______
When did the symptoms appear? ______First date of similar illness? ______
Condition related to employment? _____ Yes (Worker’s Compensation) _____ No (Another type of insurance) ______
Condition related to auto accident? _____ Yes (Auto liability or collision) _____ No (Another type of insurance) ______
If yes, in what State did the accident occur ______Condition related to any accident: _____ Yes _____ No
MEDICAL TREATMENT and MEDICATIONS
Please list the name, dosage, purpose for each medication you are taking. Also give the name of the doctor who is prescribing each medication.
______
INFORMED CONSENT
Welcome to my practice. Psychotherapy is not easily described in general statements. It varies depending on the personalities involved, and the particular problems you are experiencing. Psychotherapy can have benefits (better relationships, solutions to specific problems, and significant reductions in feelings of distress) and risks (uncomfortable feelings like sadness, guilt, anger, or frustration).
Discontinuing psychological services can be a useful process that may be initiated by you or me. Should you decide to stop counseling, I request that you discuss it with me. If at any time I determine that you require care that I cannot provide, I will refer you to a professional or agency that I believe can meet your needs.
Thank you.
CLIENT CONTACT INFORMATION
Clients(or responsible party) must providecontact information.
FEES AND SERVICES
Forty eight (48) hours notice is required to change or cancel an appointment. The fee for a late cancellation or no show is $135.00. This will be reported to your insurance company.
Appointments are usually 40 minutes, but can occasionally be shorter or longer. One session per week is typical, but more or less frequent sessions are available if you and I decide that is better for you. You may receive a copy of the fee schedule for all fees and services from the front desk if you request it.
Payment is due the day service is rendered. Because non-payment is disruptive to the therapeutic process, no appointments will be scheduled and no service will be rendered if there is a balance due for any service or fee. However, I will make a referral if you call and request it.
For minors, the adult who brings the child to the appointment is financially responsible to this office.
You are responsible for the portion of the fee not covered by your contract with your insurance company. Insurance represents a contract between the insurance company and the family. It is the responsibility of the client or his / her family to know the insurance benefits and limits of coverage. This office will help you inquire about what those benefits are, if requested, but that does not relieve the family from financial responsibility.
If I am an “out of network” provider, my office will not bill your insurance company for payment, and you will be responsible for full payment of my fee. You can still utilize your health insurance for psychotherapy with me. You may apply for reimbursement from your insurance company. If you chose to do this, I will prepare for you a statement of services. You may then be reimbursed directly by the insurance company for services you have received and paid for at my office.
Some people chose to not utilize their insurance coverage because they want: greater control over treatment decisions; increased confidentiality because if I am not billing the insurance company, I will not divulge any of your personal, confidential information to your insurance company; no limitations from outsiders about what we can talk about and work on in therapy; and avoidance of termination of future coverage resulting from a psychiatric diagnosis.
If your insurance company offers a pre-tax medical Flexible Spending Account (FSA) or if you have established a Health Savings Account (HSA), I recommend that you consider using it for your out-of-pocket cost for psychotherapy.
If your account becomes delinquent, I have the option to use legal means to secure payment. This would involve contacting my attorney, which would require me to disclose otherwise confidential information. My attorney will add his fee (30% – 40 % of the bill) to the amount owed to me.
Because of the extremely sensitive nature of psychotherapy, I do not release case process notes. Should you want treatment information released, you and I will decide which will best serve your needs: a phone call, letter or a treatment summary. Time spent outside of a session in consultation with you or collateral individuals (medical doctor, teacher, etc.) or spent writing a document is billable at $200.00 per hour.
Printing or copying of documents will be billed at $25 per document, or .75¢ per page, whichever is greater.
Returned check fee: $25.00 plus bank fees.
COURT TESTIMONY AND LEGAL INVOLVEMENT
I am not a forensic psychologist. I have never testified before a court. I do not provide any services, opinions or documents for court or legal purposes.My services are limited to enhancing the health and functioning of my clients. If you need forensic services I will be happy to refer you to other psychologists who provide that service. By signing this agreement and beginning treatment with me, you agree that none of our conversations, treatment, diagnoses, etc. can be used for any legal purposes, and that if my records and/or oral testimony are subpoenaed, you will then be billed for any attorney fees, costs, and/or expenses incurred for the time required to comply with or quash it, and for my time related dealing with the subpoena. Because of the difficulty of legal involvement, I charge $450.00 per hour of time spent in preparation, travel, appearance, etc. and require that a retainer of $3000.00 be paid in advance.
CONTACTING ME
I am rarely available by telephone. You may leave a message for me and I will return your call. If you believe you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or Number Nyne at 405-325-6963or call the Crisis Contact Helpline at 405-848-2273. If you have an emergency, go to the nearest hospital.
CONFIDENTIALITY and PROTECTED HEALTH INFORMATION (PHI)
As a “Licensed Health Service Psychologist” in the state of Oklahoma, I am charged with the responsibility of informing you of the law regarding your legal rights and my professional responsibilities. Because you have selected a licensed psychologist, you have chosen a professional who guarantees you the right to privileged communication. Thus, information obtained in the course of you receiving psychological services is privileged, and will be kept confidential with the following exceptions:
Information may be released when you give specific written permission, unless, in my professional judgment it would be harmful to you to do so.
I must notify certain third parties if, in my judgment, you present a clear and present danger to yourself or others, or if child or elder abuse is suspected.
Insurance companies or other third party payers have the right to information necessary to process claims including: diagnosis, type and dates of services, symptoms, treatment plan, and progress.
My office staff will be given information sufficient to perform the functions of billing, insurance claims preparation, and follow-up. For questions regarding billing, call 329-7923 (voicemail 7) Monday – Friday, 9:00 am – 3:00 pm.
I may disclose privileged information in order to defend myself as a result of any action filed by you with a court, regulatory board or agency.
Court orders issued by judicial authority must be honored.
HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT (HIPAA)
Patient’s Rights:
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of
protected health information (PHI) about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternativelocations. For example, you may not want a family member to know that you are seeing me. Upon request, I will send your bills to another address.
Right to Inspect and Copy – You have the right to inspect and / or obtain a copy of PHI in my records used to make decisions about you for as long as the PHI is maintained in the record. I may deny you access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the amendment process.
Right to Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
Right to Paper Copy - You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will send you a copy of the revisions.
Questions and Complaints:
If you have questions about this notice, disagree with a decision I make about access to your records, have other concerns about your privacy rights or believe your rights have been violated, please feel free to discuss it with me at 405-329-7923. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
AUTHORIZATION, AGREEMENT, and CONSENT
Appointment information is considered to be “Protected Health Information” under HIPAA. By my signature, I am waiving my right to keep this information completely private, and requesting that it be handled as I have noted above.I authorize the release of any information by Dr. Wahkinney and / or her agents necessary to process insurance claims and verify the availability of insurance benefits. I also authorize Dr. Wahkinney and / or her agents to apply for benefits on my behalf for covered services rendered by her. I authorize payment be directly to her. I understand that I am financially responsible to her for charges not covered by my insurance or this assignment. I permit a copy of this authorizationto be used in place of original. This authorization may be revoked by me in writing at any time. I have read and understand the CLIENT INFORMATION SHEET and INFORMED CONSENT, and agree to the terms.I understand that Dr. Wahkinney may hold or terminate care based on these policies. I have asked for and been provided with acceptable answers to questions about this information.
Date ______Signature of Responsible Party ______
(FOR MINOR: Guardian, Authorized Representative)
Updated: 5-2013