Access Behavioral Health, Inc.
Clinical Self Assessment
Name: Date:
What concerns do you have for the therapist today? Why are you seeking therapy at this time?
Please circle the description which fits you most:
Your Mood:
Very depressed Down/Low Content Happy Very Happy
Your Pleasure and Interest in Activities:
None Poor Average Good Excellent
Feelings of Guilt:
Excessive Some Little Rare None
Your Energy Level:
None Poor Average Good Excellent
Your Concentration:
Extremely Poor Poor Average Good Excellent
Your Sleep:
Extremely Poor Poor Average Good Excellent
Your Appetite:
None Poor Average Good Excellent
Have you experienced any thoughts of hurting yourself or others? (If yes, please explain)
Please list any current medical problems:
Please list any prescription or over the counter medications you are taking, including dosage:
Please list your use of caffeine, alcohol, tobacco and other drugs/ substances in the last month:
Patient or Guardian’s Signature
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Client Information:
Name: DOB: SSN:
Home Address:
City: State: Zip:
Home Phone: If needed, may we contact you at home? Yes No
Work Phone: If needed, may we contact you at work? Yes No
Cell Phone: ______If needed, may we contact your cell? Yes No
Email Address:______
Responsible Party Information (Please fill out if client is minor)
Name: ______
Mailing Address: ______
City: ______State: ______Zip: ______
Home Phone: If needed, may we contact you at home? Yes No
Work Phone: If needed, may we contact you at work? Yes No
Employer: ______
Cell Phone: ______If needed, may we contact you by cell phone?Yes No
Emergency Contact:
Name: ______Relationship:______Phone:______
POLICY HOLDER INFORMATION:
Insurance Company: Insurance ID # ______
Policy Holder Name: Policy Holder Date of Birth
Policy Holder’s Employer:
Policy Holder address if different than client: ______
Client relationship to insured (please circle one): Self Spouse Child Other
How did you hear about us? (check one) { } Physician { } Yellow Pages { } Insurance
{ } EAP program { } Friend/Relative { } Brochure { } Website { } Other:
Is this appointment for a child custody evaluation? { } Yes { } No
****Please return this form with a copy of your insurance card and driver’s license.
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AUTHORIZATIONS TO RELEASE INFORMATION
Welcome to Access Behavioral Health, Inc. This packet contains important information about services and business policies as well as information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regards to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. The law protects the privacy of all communications between a patient and a therapist. In most situations, information can only be released to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanced consent.
I, authorize
(Client’s name) (Provider’s name)
to release and/or obtain the following information related to my treatment:
(Check all that apply. Only those listed will be allowed to call or obtain information. If using insurance, this must be checked for billing purposes. )
Insurance Company Name: Phone:
Employer Name: Phone:
Spouse Name: Phone:
______Parent or Guardians:______Phone:______
Other Relationship ______Name: ______Phone:
Primary Care Physician Information:
Check here if you DO NOT have a Primary Care Physician.
Doctor:______Phone: Address:______
*Please Check One: I give my permission to release any applicable information to the above doctor.
I give my permission to release only medical information to the above doctor.
Do Not release any information to my primary care physician.
Time limitation for this release is: OR ______No limitation
I understand I may revoke this authorization at any time.
I further understand that this information will be confidential and cannot be released to any party not named above, including spouses or parents. Federal law prohibits myself or any of the above named individuals/ agency from re-disclosing this information without my signed consent. Due to HIPAA regulations, we usually require the patient to personally pick up copies of documents or confidential information. We do not usually mail or fax confidential information due to HIPAA. We also do not mail confidential information to other parties, such as attorneys, without a court order.
Billing information and statements are not considered confidential medical information and will be sent to the patient’s home address.
_____ Yes, I give permission to call me for reminder appointments. The best number is call is ______
_____ I decline to receive reminders of my appointments. If permission is not given, I understand that it is possible I will not be informed of scheduling changes when the provider is unable to be in the office.
Signature of Patient or Parent or Guardian Date
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Permission to Treat/ Permission to Render Services
I, , give permission to
Patient’s name Therapist’s name
and Access Behavioral Health, Inc. to provide me treatment services.
______
Signature of the patient Date
OR IF THE PATIENT IS A MINOR:
I, , give permission to
Parent’s/ guardian’s name Therapist’s name
and Access Behavioral Health, Inc. to render treatment to
,
Patient’s name
whose relationship to me is child Other (specify)
Signature of the patient
Signature of parent/guardian
Date
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MEDICATION MANGEMENT POLICY
Access Behavioral Health, Inc., has formulated the following medication management policy to:
Provide additional safety monitoring of patients taking medications
Reduce risk to patients who may abuse medications prescribed
Reduce risk and liability for providers due to patients who do not
follow the treatment plan or who abuse medications
In order to be considered an active patient at Access Behavioral Health, Inc., a patient must be seen by either a therapist or a psychiatrist at least every ninety (90) days. Since medication management follow-ups are only 15 minutes, seeing a therapist will provide a safety net to identify any patient who might become suicidal or who may be having reactions to medications.
Medications will not be written for more than 90 days, unless the patient has been treated by the same psychiatrist for at least 3 years and is consistent with the same medication and dosage. This assures that all patients are seen in an attempt to rule out any adverse situations that would create liability for providers or Access Behavioral Health, Inc. Access Behavioral Health does not feel it is prudent to write prescriptions without seeing patients on a regular basis. We understand this may not be convenient for those patients who use mail order services, but this is necessary because of the additional liability for providers and for Access Behavioral Health, Inc.
All medication management patients must have lab tests at least once a year. The psychiatrist will determine if more than one test per year is needed.
If the patient is taking medications for depression or other illnesses that might involve patient safety, we require that the patient also see a therapist on a regular basis. A new patient must be seen at least once by a therapist at Access Behavioral Health, or request copies of their current therapist’s notes to provide a history for the chart.
Although the psychiatrist will try to return phone calls and process medication refill requests as soon as possible, there is THREE-DAY notice required for refill requests. PRESCRIPTIONS WILL NOT BE FILLED ON FRIDAYS. If the patient feels it is a medical emergency, the patient should immediately go to the nearest emergency room. The psychiatrist will be called by the emergency room if needed.
If a patient requesting a medication refill has a balance, our policy is to fill the prescription for only seven days at a time until the balance is cleared. A patient must have a follow-up appointment scheduled before a refill request will be processed.
I have read and agree to follow this policy:
______Date ______
Patient/ Parent or Guardian’s signature
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Patient Bill of Rights
Statement of Patients’ Rights
Patients have the right to be treated with dignity and respect.
Patients have the right to fair treatment. This is regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
Patients have the right to have their treatment and other patient information kept private.
Patient records cannot be released without patient permission except as required by law or in accordance with HIPAA regulations.
Patients have the right to information from staff/providers in a language they can understand.
Patients have the right to have an “easy to understand” explanation of their condition and treatment.
Patients have the right to know about their treatment choices, regardless of the cost or whether or not they are covered by insurance.
Patients have the right to get information about Access Behavioral Health, Inc. services and role in the treatment process.
Patients have the right to professional information about providers.
Patients have the right to know the clinical guidelines used in providing and/or managing their care.
Patients have the right to file a complaint or grievance with the administration of Access Behavioral Health, Inc.
Patients have the right to know about State and Federal laws that relate to their rights and responsibilities.
Patients have the right to know of their rights and responsibilities in the treatment process.
Statement of Patients’ Responsibilities
Patients have the responsibility to give providers information they need. This is so the provider can deliver the best possible care.
Patients have the responsibility to let their provider know when the treatment plan no longer works for them.
Patients have the responsibility to follow their medication plan. They must tell their provider about medication changes, including medications given to them by other providers.
Patients have the responsibility to treat those giving them care with dignity and respect. This includes any support staff, such as people who make appointments.
Patients should not take actions that could harm the lives of Access Behavioral Health, Inc., employees, providers, or other patients.
Patients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits. A fee of $35 is charged if the patient does not show or if the cancellation is made in less than 24 hours of the appointment time. Reminder phone calls may be made by our office. This is only a courtesy to our patients. The patient is ultimately responsible for tracking their appointment day and time.
Patients have the responsibility to ask their providers questions about their care. This is so they can understand their care and their role in that care.
Patients have the responsibility to meet their financial obligations for their services. Should a problem arise with meeting this obligation, patients must communicate with their provider to resolve the problem.
Patients have the responsibility to follow the plans and instructions for their care. The care is to be agreed upon by the member and provider.
I have read and understand my Patient Rights and Responsibilities
______Date: ______
Patient or Guardian Signature
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Fees and Collections Policy
I understand that I am fully responsible for payment of services rendered to me, by the above practice, BEFORE the session begins. It is company policy to collect all co-payments BEFORE each session with a therapist or doctor. I realize that my mental health benefits have been determined prior to this appointment and that all co-payments and co-insurance payments are due at the time of service. I understand that I am financially responsible for charges not covered and agree to guarantee payment for any balance due in excess of any amount paid by individuals, agencies, and/or insurance companies. In the event of default, I agree to pay all costs of collections including court costs and reasonable attorney’s fees. I understand that if the insurance policy that is being used is out-of-state that Access Behavioral Health, Inc. reserves the right to collect fees when services are rendered and reimburse me when the insurance company makes payment.
**PLEASE TAKE NOTICE**
NO-SHOW / LATE CANCELLATION FEES
A fee of $35.00 will be added to the account of any patient failing to cancel an appointment 24 hours prior to appointment time. A patient is considered a “no-show” if the appointment is not kept and not canceled 24 hours prior to the scheduled time. These charges are not covered by health insurance benefits and are the responsibility of the patient/responsible party. Patients with no-show fees must clear the charge PRIOR to the next scheduled appointment. Unpaid past-due charges will be turned over to a collection agency. THERE WILL BE NO EXCEPTIONS.
Dedication to mental health treatment involves a commitment from your clinician to reserve time and be prepared for your session. Your commitment is to attend all scheduled appointments and follow through with all treatment recommendations. Consistency in keeping appointments is important to the patient’s treatment plan. In addition, multiple cancellations, even with advance notice, do not reflect patient commitment to the treatment plan and may also result in the patient being referred to another agency. Three cancellations in a row, or five cancellations within a six-month period (even if appropriate 24 hour notice is given) are considered a lack of investment in treatment.
Below is a list of our standard charges, which you will be responsible for paying if your insurance company denies a claim:
Initial Visit for a DIAGNOSTIC INTERVIEW, with MD $160.00
Initial visit for a DIAGNOSTIC INTERVIEW, with Psychologist $150.00
Initial visit for a DIAGNOSTIC INTERVIEW, with Social Worker $125.00
Visit for a FOLLOW-UP SESSION, with MD $ 65.00
Visit for a FOLLOW-UP SESSION, with Psychologist $125.00
Visit for a FOLLOW-UP SESSION, with Social Worker $100.00
Hypnosis session with Ronald D. Dobbs, LCSW, NBCDCH $125.00
CUSTODY EVALUATIONS: (In the event that you are here for a custody evaluation) I understand that Access Behavioral Health, Inc. will perform a custody evaluation based on a court order that designates the psychologist appointed by the court for such purposes. Custody evaluations will not be billed to my insurance carrier. I understand that a minimum retainer of $1,750 per adult named in the court order will be due prior to the evaluation. In the case that the order is cancelled, the retainer will be billed at $200.00 per hour for services rendered on the case. I understand that additional retainer amounts may apply in atypical cases. Costs for court appearances and depositions are additional to the retainer for the custody evaluation and must also be paid prior to the court or deposition date.