KC Family Hope Center

KC Family Hope Center

Karen Casseday, MN, ARNP, PMHNP-BC

1740 NE Riddell Rd #110 Bremerton, WA 98310

Phone (360) 567-6109 Fax (360) 479-0143

Patient Information

First Name: ______MI: ______Last Name: ______

ircle): Married, Physical Address: ______

Mailing Address: ______

City______State ______Zip ______

May we send correspondence to this address? Yes/No Date of Birth: ______/______/______

Age: _____ Gender: M / F

Minor: Yes [ ] No [ ] If Yes, Parent(s) Names: ______

Marital Status: (Please circle): Married / Single / Other

Home Number: ( ) ______O.K. to leave message? Yes [ ] No [ ]

Cell Number: ( ) ______O.K. to leave message? Yes [ ] No [ ]

Work Number: ( ) ______O.K. to leave message? Yes [ ] No [ ]

Employer: ______

Emergency Contact: ______Telephone Number: ( ) ______

Relationship: ______

Who should we thank for the referral? ______

Other Providers

Primary Care Physician: ______Phone #: ______

Therapist: ______Phone #: ______

Care Provider (if applicable): ______Phone #: ______

Is the client a resident of an institution or member of a day program? Yes [ ] No [ ]

If so, please list: ______

* Please provide your insurance card/s & photo identification to scan/copy for our records

Primary Insurance Information

Insurance Co. Name: ______

Insurance ID #: ______Group # ______

Subscriber’s Full Name: ______Subscriber’s DOB: _____/_____/_____

Subscriber’s address (if different from patient): ______

______

Relation to subscriber: spouse / child / parent / other

Subscriber’s Employer: ______

Employer’s Phone Number: ______

Secondary Insurance Information

Insurance Co. Name: ______

Insurance ID #: ______Group # ______

Subscriber’s Full Name: ______Subscriber’s DOB: _____/_____/_____

Subscriber’s address (if different from patient): ______

Relation to subscriber: spouse / child / parent / other

Subscriber’s Employer: ______Employer’s Phone Number: ______

Financial Responsibility

Responsible Party Information (if different than insured/subscriber):

Name: ______Phone #: ______

Address: ______

Date of Birth: ______

Some procedures may not be paid by your insurance company. A telephone call with your provider is one category which may not be covered by your benefits. Please be advised of the following charges.

- Brief phone call (5-10 min)$20.00

- Intermediate phone call (11-20 min)$40.00

- Lengthy phone call (21-30 min)$60.00

-Requests for additional paperwork/documents outside of appointments

(<15 min)$25.00

(15-29 min) $45.00

(30-45 min) $90.00

(46-60 min) $120.00

Insured Assignment and Release of Information:

I hereby authorize my insurance benefits to be paid directly to the provider. I realize that I am responsible to pay for any non-covered services, and that I will be liable for a monthly finance charge of 1.0% or $5.00, whichever is greater, on balances over 60 days past due. I understand that I am also responsible to pay a $50.00 charge for failure to arrive at my appointment at the scheduled time or failure to provide 24 hours advance notice for cancelled appointments. If not paid according to terms I understand that my account may be turned over to a collection agency, in which case I agree to pay all additional fees assessed in collection of the debt. These fees include collection agency fees and attorney fees. I understand that there will be a $25.00 charge assessed on all returned checks.

I hereby authorize the release of pertinent medical information to the insurance company if necessary, to assist in claims processing as requested by the insurance company.

______

Patient Signature (All patients over 13 years old required) Date

______

Responsible Party/Guardian/Parent Signature Date

PATIENT TREATMENT CONTRACT

As a patient of Karen Casseday, ARNP, I freely and voluntarily agree to accept this treatment contract as follows:

• I agree to take responsibility for my treatment. I will schedule and keep appointments within the agreed upon time frame. I understand that the need to cancel an appointment, once scheduled, should be the exception and not the rule.
• I agree to arrive on time and prepared for my appointment. This means: I will come prepared to pay any co-pay I may have. I will advise the office of any medication changes I have had since my initial visit, and I will be prepared to list all of my medications, including dosing instructions. I will write out and bring a list of any questions or concerns that I may have, including, but not limited to, potential side effects that I have experienced since my last follow-up appointment with the provider.
• I agree to come in sooner than my previously scheduled follow-up appointment if my provider feels it necessary.
• I agree to take all medication as prescribed and to notify my provider with any questions and/or concerns I may have before decreasing/increasing, stopping, or altering medications prescribed by my provider.
• I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of the law and of this agreement and would result in my treatment being terminated without any recourse for appeal.
• I agree that some of my prescriptions can only be given to me at my regular office visits and that a missed visit may result in my not being able to get my prescription until I talk with my provider. I understand that I must allow two business days to process refill requests.
• I agree and understand that my provider will not renew any of my medications if it has been 6 months or more since my last follow up appointment.
• I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I understand and agree that my provider will not replace prescriptions for controlled substances regardless of why it was lost, stolen or damaged.
• I agree to be completely truthful and honest with my provider.
• I understand that medication alone may not be sufficient treatment for my condition. Therefore, I agree to participate in counseling as discussed and agreed upon with my provider.
• I agree to get lab work done as ordered by my provider and to do so within the requested time frame.
• I understand that I may conclude services with my provider at any time for any reason. However, I will remain fiscally responsible for any unpaid balance from services already provided.
• I understand that violation of any part of this treatment contract gives my provider the option of immediately concluding treatment services with me.

My signature indicates that I have read or been read, understand, and agree to the terms listed within this treatment contract. I also understand that patients under the age of 18 years must also have their parent or legal guardian sign this treatment agreement and that their signature implies responsibility in overseeing and supervising the underage patient to assure compliance to this treatment agreement.

____________

Patient Name

______Date: ______

Patient Signature (all patients over 13 required)

______Date: ______

Responsible Party/Guardian/Parent (signature required if minor)

Notice of Privacy Practices

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. *Please carefully review pages 1 & 2 and retain for your records.

Understanding Your Health Record Information

Each time you visit or contact your mental health care provider, a record of this contract is made. This information, often referred to as your “chart”, serves the following purposes: 1) a basis for planning your care and treatment, 2) a means of communication among the many health and mental health professionals who contribute to your care, 3) a legal document describing the care you received, 4) a means by which you or a third-party payer can verify that services billed were actually provided, 5) a source of data for education, research, and planning, 6) a source of information for public health officials charged with improving the health of the nation, and 7) a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record (chart) and how your mental health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access this information, and helps you to make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your mental health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to: 1) obtain a paper copy of the notice of privacy practices upon request, 2) request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522 (a), however, we are not required to agree to such a restriction, 3) receive confidential communications of your protected health information per 45 CFR 164.522 (b), 4) inspect and copy your mental health record as provided for in 45 CFR 164.524, 5) amend your record as provided in 45 CFR 164.526, 6) receive an accounting of disclosures of your mental health information as provided in 45 CFR 164.528, 7) request communications of information by alternative means or at alternative locations, 8) revoke your authorization to use or disclose mental health information except to the extent that action has already been taken.

My Responsibilities

Karen S. Casseday, ARNP is required to: 1) maintain the privacy of your mental health information, 2) provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, 3) abide by the terms of this notice, 4) notify you if we are unable to agree to a requested restriction, 5) accommodate reasonable requests you may have to communicate information by alternative means or at alternative locations. We will not use or disclose your information without your authorization, except as described in this notice.

We reserve the right to change our practices and to make any new provisions effective for all protected health information we maintain. Should our information practices change, we will post the revision in our lobby and upon request mail a revised notice to the address you’ve supplied to us.

Correctional Institutions: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, mental health information necessary for your continuity of care and the safety of you or other individuals. Furthermore, information may be released to the State monitoring program (probation) following release from a State correctional facility.

My Responsibilities (Continued)

Operator of a Care Facility: We may provide information to an operator of a care facility in which you reside (nursing home, convalescent center) to assist with any special needs.

Law Enforcement / Legal Actions: We are required to report incidents of child or adult abuse or neglect and/or provide information as necessary to assist in the investigative process to the police or appropriate social service agency. We may disclose information to the Coroner or Medical Examiner, or limited information may be disclosed to law enforcement as required by law to assist in fulfilling their duties. We may disclose information upon receipt of a Court Order. Furthermore, information related to a client’s commission of a crime at 1740 NE Riddell Rd Ste 110 Bremerton, WA is not protected.

In the course of an investigation for involuntary treatment and / or as a result of a civil petition for involuntary treatment: We are authorized to share your information with the county prosecutor, your attorney, the court, Department of Social and Health Services, to a protection and advocacy agency, and others as allowed under the law regarding involuntary commitment proceedings, RCW 71.05 or 71.34.

Duty to Warn: We are required to disclose information to the proper authorities (law enforcement) and the intended victim if we suspect serious harm to another is intended or threatened.

Oversight: Information may be reviewed by a regulatory or oversight committee to ensure adherence to required guidelines. This may include, but not be limited to, state, federal, and regional audits reviewing business practices, billing procedures, clinical practices and confidentiality issues.

Payments / Benefits: We may disclose information to assist in collecting payment for services or to assist you in accessing benefits / aid.

Health Care Providers: We may disclose information to your primary health care provider or community mental health provider for continuity of care (unless directed otherwise), or to assist with emergency medical treatment or medically necessary tests / evaluations.

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more clients, workers, or the public.

All other uses and disclosures of your protected health information will only be made with your written authorization and you may revoke that authorization at any time as provided by 45 CFR 164.508 (b).

Filing a Complaint

How to File a Complaint or Report a Problem: If you have questions or would like additional information, or feel your privacy rights have been violated and you would like to file a complaint, you may contact my office (360) 567-6109. You may also file a complaint directly with the Office for Civil Rights, U.S. Dept. of Health and Human Services, 2201 Sixth Avenue Suite 900, Seattle, WA 98121. There will be no retaliation for filing a complaint.

Effective Date: February 2, 2015.Updated 10/18/2017.

Professional Records

By law and the standards of my profession it is required that I keep appropriate treatment records which include your diagnosis, dates of your treatment sessions, and the rate at which you were billed. You are entitled to receive a copy of the records, unless I believe that you reading them would be emotionally damaging, in which case, I will provide them to an appropriate mental health professional of your choice. If you wish, I can prepare an appropriate summary. Because these are professional records, they can be misinterpreted and/or can be emotionally upsetting. If you wish to see your records, I recommend that (if deemed appropriate) we review them in my presence so we can discuss what they contain. You should be aware that you will be billed accordingly for any records copied.

Notice of Privacy Practices Signature Page

By my signature below I acknowledge receipt of KC Family Hope Center,

Karen Casseday, MN, PMHNP-BC, ARNP

Notice of Privacy Practices.

______

Patient Name

______Date: ______

Patient Signature (all patients over 13 required)

______Date: ______

Responsible party/guardian/parent (signature required if minor)

TRIALS OF PSYCHIATRIC MEDICATIONS AND REACTIONS: Please circle or highlight

Antidepressants: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Luvox (fluvoxamine), Lexapro(escitalopram), Effexor (venlafaxine), Cymbalta (duloxetine), Wellbutrin (bupropion), Remeron (mirtazapine).

Mood Stabilizers: Lithium, Depakote (valproate), Tegretol (carbamazepine), Trileptal.(oxcarbamazepine),Topamax (topiramate), Lamictal (lamotrigine), Latuda.

Antipsychotics/Mood Stabilizers: Seroquel (quetiapine), Zyprexa (olanzepine),

Geodon (ziprasidone), Abilify (aripiprazole), Clozaril (clozapine), Haldol (haloperidol), Risperdal (risperidone).

Sedative/hypnotics: Ambien (zolpidem), Sonata, Lunesta, Restoril (temazepam),

Desyrel (Trazodone), Remeron (mirtazapine), Rozerem, melatonin-OTC.

Antianxiety: Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), Valium (diazepam), Buspar (buspirone).

ADHD: Adderall (amphetamine), Concerta (methylphenidate), Ritalin (methylphenidate), Strattera (atomoxetine), Vyvanse (lisdexamphetamine), Tenex (guanfacine), Intuniv (Guanfacine), Clonidine.

Please complete your current medication list on the next page ( page10).

Current Medication List

Patient Name: ______

List any and all medications that you take and the dosing instructions for each, including any vitamins and/or supplements. It is important to remember to bring this completed list to each appointment, even if nothing has changed since your last appointment.

Name of Medication / Dosing Instructions / Prescriber
Supplements & Vitamins

Please list any and all allergies and your response: ______

Pharmacy: ______

Patient Signature: ______Date: ______

Parent/Guardian Signature: ______Date: ______

My signature represents that this is a complete list of all the medications, vitamins, and/or supplements that I take daily, including the dosages and frequency of each.

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