Parental Permission To Treat A Minor (Page 5 of 8) in pdf

Client Information and Consent Form

Name _______________________________________________________________________________

Street________________________________________________________________________________

City ______________________________________

State ____________ Zip _________________

Day Phone ________________ Night Phone _______________ Cell Phone_______________________

Email address (useful for scheduling - please print clearly) ____________________________________

Birth date ______/______/______ SS # ________/_______/________ Age ___ Sex (M/F) _______

Emergency contact person: ________________________________ Phone: _____________________

Parent, Guardian or Family Member: _________________________ Phone: ____________________

Insurance Information:

(Please give your insurance card to the receptionist so we can make a copy of it for our

records.)

Name of Insurance Co: ___________________________ Telephone:___________________________

Name of Policy Holder: ______________________ Policy Holder’s SS#:________/______/________

Policy Holder's Employer: _____________________ Policy Holder's Date of Birth: ______________

Group / Policy #:_________________ Insurance ID# (if different than SS#) _____________________

Authorization and Consent for Treatment and HIPAA Notification

I hereby give my consent to KPCC to provide evaluation, treatment and/or other services that we may

mutually determine to be appropriate.

I authorize KPCC to directly bill and receive payment from my insurance company and/or other persons

liable to pay my bill. I assign my right to receive payment directly from any available source to KPCC. I

will get authorization from my insurance company for any of KPCC’s services if it is required by my

policy. I will personally pay all charges not paid by my insurance company or anyone else.

I am aware of the KPCC “Notice of Privacy Practices” and understand a hard copy can be provided at my

request and via I understand that KPCC may make verbal summaries

or send summaries or records of my evaluation and/or treatment to my insurance/managed care company

for clinical review as part of its responsibility to manage my care. I further understand that these services

are confidential and that information about me will not be disclosed or released to anyone other than

authorized KPCC staff without my written consent, with the following exceptions: 1. Information

necessary to authorize services or pay claims will be communicated to the insurer/claims payor when

required. 2. If I disclose information in the course of evaluation or treatment which indicates I present a

clear and present danger to myself or others. 3. As mandated by state or federal law.

Signature of Client: _________________________________

Date: ________________________

If signed by guardian, guardian’s authority is based on ________________________________________________

Kanawha Pastoral Counseling Center

16 Leon Sullivan Way, Suite 300

Charleston, WV 25301 Phone: 304-346-9689

Parental Permission To Treat A Minor Page 5