Medical Psychology Center
PATIENT REGISTRATION
To facilitate accurate recordkeeping, kindly provide the information requested.
Today’s Date: ______
Patient’s Name: ______Date of Birth: ______
Address: ______Sex: ______
City/Town______Marital Status: ______
State ______Zip Code______Home Phone: ______
· Social Security #: ______Work Phone: ______
(only required, if over the age of 18 years old)
Email address: ______Cellular Phone: ______
*Subscriber’s Name: ______*Relationship to Patient: ______
*Subscriber’s Address: ______
*Subscriber’s SS#: ______*Date of Birth: ______*Employer: ______
Insurance Company Name: ______ID#: ______
Insurance Company Address: ______
Insurance Company Telephone: ______Policy/Group #: ______
Secondary Insurance Company: ______ID#: ______
(if applicable)
Secondary Ins Address: ______Policy/Group #: ______
Emergency Contact: ______Relationship: ______Phone: ______
Primary Care Physician: ______Phone:______
Address: ______
Referred by : ______Phone:______
Office Use Only:
Clinician: ______Date of 1st visit: ______
ICD-9 DX: ______DX Narrative: ______
· Required for Billing Purposes
Medical Psychology Center
Psychological Services Contract
Welcome to the Medical Psychology Center. This document contains important information about our professional services and business policies. Please read it carefully. Your clinician can answer any questions you may have regarding your therapy. Our office manager or our billing coordinator is also available to you as needed. The Director, Dr. Inz, can also be contacted if you have any additional concerns.
PSYCHOLOGICAL SERVICES: Psychotherapy is a treatment process developed between a psychotherapist and a patient. It is a voluntary contract between you and your therapist that depends on a deep trusting relationship. We know that this relationship is greatly helped by being clear and precise about what is expected and given by both parties.
Our first few sessions will involve an evaluation of your current concerns and a review of your history. By the end of the evaluation, we will be able to discuss what the nature of the problem is and how treatment will address these issues. Therapy involves a large commitment of time, money, and energy. You should feel comfortable with your therapist and the process. If you have questions about our procedures you should raise them right away. The rest of this contract will clarify the different aspects of this relationship; delineating what you can expect of us and what is expected of you. In addition to information about yourself, address, and insurance company, your signature at the end of this document signifies that you have read and understood it and are bound by its terms.
MEETINGS: Appointments generally are 45-50 minutes in duration. The frequency of meetings and the overall length of treatment are to be determined by you, your clinician, and in some situations your insurance company. If you have concerns about your treatment or feel like your experience is not to your satisfaction, then contact of our Office Manager at 978-921-4000 ext 14. You may also always call the Director, Dr. Inz, at 978-921-4000 ext. 10.
PROFESSIONAL FEES: Our fees are $195 for the initial diagnostic evaluation visit, $130 for a 50-minute individual therapy session, and $140 for family or couple therapy sessions. If your treatment is covered by insurance, the copayment, co-insurance or deductible is due from you at the time of service. We ask that you check in with the business office before your appointment and pay your portion of the fee at that time. If the office staff is not present or available, please check out after the session. We accept cash, personal checks, and credit cards (MC or VISA only).
KNOWLEDGE OF INSURANCE COVERAGE: As you know, many insurance policies have become increasingly complicated. Insurance policies with deductibles are more common than ever. If you have a deductible, the deductible is the dollar amount of health expenses that must be paid out of pocket by an individual before the insurer will pay any money toward your claims. It is very important that you know the details of your insurance coverage, including whether or not you have a deductible. It is also important for you to know whether or not you have met your deductible for the year when you begin treatment with us. If you have not met your deductible, you will be responsible for payment for sessions (the contracted amount your insurance company would pay for each session) until your deductible is met. Please be aware that when MPC is notified that your deductible has not been met, we will charge the credit card we have on file for the session charges that you have already incurred. Therefore, we strongly advise you to know the details of your insurance policy so that you are not surprised by any charges you may incur. Our Billing Coordinator can discuss this with you in more depth.
Please initial here to indicate that you understand your responsibility regarding copayments, deductibles, checking in at the beginning of each session, and general financial responsibilities. _____
OTHER OCCASIONS FOR CHARGES: In addition to office visits, there may be occasions on which you request other services from your clinician, such as writing treatment reports or summaries (e.g., disability reports), extended telephone conversations (e.g., longer than 10 minutes), attending school meetings, travel time, and consulting with other professionals beyond gathering initial information and giving periodic updates. The hourly fee for these services is $130 and is not covered by health insurance. If you become involved in legal proceedings that require our participation, you will be financially responsible for all professional time, including preparation and transportation costs, even if your clinician is called to testify by another party. [Because of the nature of legal involvement, we charge $150 per hour for preparation and attendance at any legal proceeding.]
CANCELLATIONS: If you need to cancel a meeting, you will be expected to give your clinician at least 24 hours notice (i.e., one business day). Thus, to cancel a Wednesday appointment at 4 pm, you should call your clinician no later than 4 pm Tuesday. To cancel a Monday appointment at 10 am, you will need to contact your clinician by the previous Friday at 10 am. If you miss a scheduled appointment or cancel with less that 24 hours notice, you will be responsible for a charge of $80. This charge will be applied to your credit card. Insurance companies do not provide reimbursement for cancelled or missed sessions.
It is important to note that this policy is in place to emphasize the importance of your coming, not to penalize you. We want you to come and actively participate in the treatment. Certainly it is more rewarding for us when you are fully engaged in the process and come to every scheduled appointment. However, we do enforce cancellation and no-show charges.
WHY DO WE ASK FOR YOUR CREDIT CARD? Our clinicians and practice need the guarantee that you will be responsible for meetings not held or cancelled without proper notice. Again, we do this to establish a clear process: the clinician’s time has been reserved for you and if you do not attend, we cannot bill your insurance. Thus, you will be held responsible for the fee for the session. We keep your credit card number on file with your therapist as discussed above to be used only if you miss a scheduled appointment or give less than 24 hours notice.
We may also use your credit card for services rendered by your clinician for any outstanding bill that has been appropriately provided to you. (See the above section on deductibles). This can apply to any testing performed, large co-payments balances or any service agreed to by you and provided by a Medical Psychology Center staff member.
Please ask your clinician about this. Your signature at the bottom of this document attests to your agreeing to this use of your credit card.
Please complete:
Visa MC Debit______Card #:______Expires______
In the unusual event that you do not have a credit card, alternative plans can be arranged.
COMMUNICATIONS: When your clinician is not available, our voice mail system allows you to leave a confidential message. Please be sure to leave your phone number and times that you can be reached. Your clinician will make every effort to return your call the same day. If you are having an emergency, please leave your clinician a message and then proceed to your hospital’s emergency room or call 911.
EMERGENCIES: In case of an emergency, contact your clinician. If you cannot wait for a call back, please go to your nearest emergency room or call 911. Clinicians will receive your call during their office hours and when they are out of the office they receive notification of your message. They will respond to your call as soon as possible. However if this is an emergency do not wait for a call back but proceed to your emergency room or call 911.
REGARDING CONFIDENTIALITY: The law protects the privacy of all communications between patient and clinician. In most situations, we can release treatment information to others only if you sign a written authorization form. Your signature on this Agreement provides consent for communication as follows:
· If you are using insurance, information about your treatment will be disclosed to the insurer for purposes of administering benefits and managing care. This includes your diagnosis and, in some cases, treatment plans and progress reports. By signing this Agreement, you agree that we can provide requested information to your carrier.
· Your clinician will need to share protected health information (PHI) with other members of the practice group for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality.
· Financial information may be disclosed to a collection service or to a small claims court for the purpose of collecting overdue payments.
· If you are of danger to yourself or someone else, your clinician is ethically and legally required to contact the authorities.
MINORS & PARENTS: Patients under the age of 18, unless emancipated, and their parents, should be aware that the law allows parents to examine their child’s treatment records. Unless the clinician believes this review would be harmful to the patient and his/her treatment. Privacy in psychotherapy is often crucial to successful progress, particularly with teenagers. Therefore the clinician will discuss how to protect patient privacy while also giving parents and guardians important information about the treatment.
Your signature below indicates that you have read this contract and agree to its terms and also serves as acknowledgement that you have received the attached “Notice of Policies and Practices to Protect the Privacy of Your Health Information” form.
______
Print Patient Name
______
Signature of Patient or Legal Guardian Date
______
Signature of Patient or Legal Guardian Date
______
Signature of Clinician Date
MEDICAL PSYCHOLOGY CENTER
100 Cummings Center, Suite 456J
Beverly, MA 01915-6106
Tel. (978) 921- 4000
Fax. (978) 921-7530
Authorization for Request of Information
I, ____ authorize ______
Name (please print) Medical Psychology Center – Suite 456J
Beverly, Massachusetts 01915-6106
Date of Birth
Social Security Number
q To Request From______
(name)
______
(address)
q To Disclose To ______
(name)
______
(address)
for the purpose of:
Method for Releasing Information: Written Telephone
(Check all that apply) Conference Other:
Facsimile
I understand that:
1) I am not giving permission for any redisclosure of this information other than specified above.
2) My consent will become invalid after the termination of my treatment.
3) I may revoke my consent at any time except to the extent that action on it has already been taken.
4) A photocopy of this statement will provide sufficient evidence of my consent for release
of information.
SIGNATURE: ______DATE:
WITNESS: