Psychiatric Intake Form (Page 7 of 11) in pdf

so we can help you determine if your provider is covered by the new plan. Any claims returned due to lapse in insurance

company will be transferred to client responsibility. If your insurance plan requires pre-authorization for services, it is

ultimately the responsibility of the patient to obtain this authorization prior to being seen by your provider. If you fail to

obtain authorization, any and all charges incurred and not reimbursed, will be your financial responsibility.

Since you cost-share with your insurance company, we do our best to estimate your portion at the time that you check in.

Despite our best efforts it is possible that once we get the claim back (usually 3-6 weeks after it is submitted) your cost-

share may be higher than originally anticipated. We will notify you about any balance due with a monthly statement. If we

overestimated the cost-share, the credit will be applied towards your future visits unless you specify otherwise. At the start

of each new calendar year in January, with new insurance plans taking effect along with new deductibles to be met, we will

be re-verifying benefits and collecting your full visit fee that will be applied to your deductible, at the time of service.

Collections Efforts

For any outstanding balances on your account, you will receive a statement a minimum of once per month. If an unpaid

balance remains after 60 days, you will receive a phone call from our office staff to work out a payment plan. If you believe

that there is an error on your statement, please let us know as soon as possible so we can research the issue.

Unpaid balances without a payment plan initiated after 120 days will initiate a phone collections effort by our third-party

collections agency for recovery, and some identifying confidential information will be released in this process. This may

negatively impact your credit. It is very important that you up- date your contact information with us to ensure that you

receive your statements in a timely manner and are aware of your financial responsibility.

Distinguishing between an emergency, urgent, and non-urgent request

If you have an urgent need for consultation (medication side-effects, increase in symptoms, etc.) you should call the main

office number and let our administrative staff know it is an urgent request. After hours and on weekends if you have an

urgent request you should call the crisis clinic 1-866-4-CRISIS (1-866-437- 4747), and please leave a message on your

provider’s extension as well as your therapist’s extension using the dial by name directory (206-242-8211 selection 6)

Many issues including insurance or billing questions, and appointment changes, can be resolved during normal business

hours, Monday through Friday 8 am – 7 pm, and will be handled by our administrative staff.

Confidentiality

We are compliant with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy

protections and patient rights with regard to personal health care information (PHI). HIPAA requires that we provide you

with a Notice of Privacy Practices. This Notice, which is attached to this agreement, explains HIPAA in detail and its

application to your personal health care in- formation. An electronic copy of this notice can be found on our website at

In the event of an emergency (you feel suicidal, homicidal, or have a medical emergency) you should call 911 or go to the

closest emergency room.

Notice of Privacy Practices

This section describes how medical information about you may be used and disclosed and how you can get access to this

information. Please review it carefully.

You have the right to:

•

Get a copy of your paper or electronic medical record

•

Correct your paper or electronic medical record

•

Request confidential communication

•

Ask us to limit the information we share

•

Get a list of those with whom we’ve shared your information

•

Get a copy of this privacy notice

Psychiatric Intake Form Page 7

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