Basic Information
Welcome and thank you for choosing our facility for your behavioral health needs. Please read and fill this packet out completely. If you have any questions, please ask our
front desk staff.
Emergency Contact Information
We do provide a courtesy call to remind you of an upcoming appointment. Please be aware that
while we do provide a courtesy call, it is up to you as a patient to keep track of your scheduled visits.
When calling for appointment reminders, cancellations or to speak with you about your treatment
plan please indicate below your preferences so we may best protect your privacy.
Charges Assessed-Failure To Attend Scheduled Visit
All patients unable to withhold scheduled appointments are required to notify the practice one business day prior to the appointment. Our reception desk accepts calls from 9:00 am until 5:30 pm Monday through Thursday and 9:00 am until 1:00 pm on Friday. No-Shows or last minute cancellations prevent The Institute of Neurobehavioral Services from providing care to patients experiencing crisis or urgent needs for treatment. Please consider that you may experience this at some point and will appreciate others providing ample notice of cancellation, allowing you to receive necessary help in a crisis.
All patients who fail to notify the practice within ample time (24 hours not including weekends or
holidays) of canceling a scheduled appointment will be charged a fee at a rate of $50 for 30 min psychiatry appointments and $100 for 1 hour therapy or combined therapy/medication management appointments. If three appointments in a row are not attended, or the doctor does not see a patient for more than eleven calendar months the patient will be discharged from the clinic.
Authorization and Release
I hereby give consent to The Institute of Neurobehavioral Services to release any medical information necessary to process any insurance claim(s). I also give consent for the direct payment of benefit under my health insurance plan to The Institute of Neurobehavioral Services. I authorize the release of any information including the diagnosis and records of any treatment or examination rendered to my child, parent or myself during the period of such care to third party payers and/or other health care practitioners. This includes the forwarding of complete progress notes or initial evaluations to my primary care physician to secure referrals and/or authorizations to continue care at The Institute of Neurobehavioral Services. I understand that my insurance carrier may pay less than the actual bill for services and therefore agree to be responsible for the balances for services rendered on my behalf or on the behalf of my dependents.
Prescription Refills
A prescription refill request is required at least 72 hours prior to running out of any medications.
From the time our office receives the pharmacy/patient request, we still require at least 72 hours to
have it approved. Multiple calls within a 72-hour time frame does not ensure that the prescription
request will be processed in a timelier manner.
In order for the physician to approve the refill request, the patient must have an upcoming
appointment scheduled with the physician. If an appointment has not been scheduled, there will be
a prescription refill delay.
Physician will only approve 90-day prescriptions at the time of patient visit.
Completion of Forms by The Physician/Therapist
All forms that require the physicians and/or therapists information (e.g. return to work form, FMLA
paperwork, prior authorization forms for medications), please allow a one-week minimum for the
physician and/or therapist to locate all documents needed to support the form request.
Please Note: There is a documentation preparation fee.
1. The patient must be seen within one month of request for form completion.
2. A fee of $25-$75(1-2 pages $25, 3 or more $75) is to be paid at the time the form is picked up.
3. Forms will be completed within two weeks of the date they are submitted.
4. Only your primary provider, here at the office, will complete any/all forms.
The “return to work” or “return to school” notes will be given at no extra charge.
Client History
Please complete the following as thoroughly as possible. Please be honest with your answers so a
correct assessment can be made, and the best care provided for you. This information will remain
confidential in your record. Thank you.
Daily Functions – Can you do the following?
Psychiatric Hospitalizations
If “Yes”, Please complete the following information.
Medications
Please list the medications (including non-prescription medications, health foods, and vitamins) you
currently take. Please include the strength and dosage
Family History
(Immediate father, mother, brothers, sisters, grandparents)
Concerns, please check all that apply
Thank you for taking the time to complete this history. Our providers are dedicated to providing
you with the best care available and will be with you shortly. Feel free to ask any questions you may
have, we will do our best to assist you.
(patient name) authorize and request that The Institute of Neurobehavioral Services, S.C. and it’s entities provide
psychological examinations, treatment and/or diagnostic procedures which now or during the
course of my care as a patient are advisable. I understand that the frequency and type of treatment
will be decided between me and my psychological provider (psychiatrist, counselor or social
worker) and will be fully explained to me in a verbal agreement.
I also understand that if I am covered by an insurance carrier and/or managed Care Company and
they elect not to cover or authorize recommended behavioral healthcare, I may elect to continue
this care at my own cost. I understand that I am responsible for payment for any services not paid
by my insurance carrier and/or managed Care Company including charges for missed or cancelled
appointments.
I further understand that this consent will be enforced as long as I seek care from The Institute of
Neurobehavioral Services and its entities and this consent may be revoked at any time, at my
request. I understand that such revocation must be presented to my provider both verbally and in
writing.
If the patient is unable to consent to treatment, I attest that I have legal power of attorney/custody
of this individual and I am authorized to initiate and consent for treatment and/or legally authorize
to initiate and consent to treatment on behalf of this individual.
Our Financial Policy
All patients must complete our Information and Insurance form before seeing the doctor.
Patients with Insurance
You are responsible for deductibles, co-pays, non-covered services, co-insurance and items
considered “not medically necessary” by your insurance company. Please pay co-payments and co-insurance amounts as services are rendered. The remaining balance should be taken care of within ten (10) days of receiving our statement. If you and your insurance carrier make a payment
exceeding your balance, re-imbursement will be remitted.
Financial Honesty and Ethics
In order to maintain a respectful and beneficial working relationship, it is expected that patient's be honest with this clinic in all affairs, medical and financial. This office does not accept all insurance plans or combination of insurance plans, such as the combination of Medicare and Medicaid. In the event that we do not accept a patient's insurance or combination of insurances we will suggest they become a private pay patient or look elsewhere for treatment. We promise to be as clear as possible regarding this information to allow patients to make the most informed decision regarding their treatment. In the event that a patient fails to provide their full and correct insurance information at any time, the full balance of their account will become their responsibility.
Patient Co-Pay and Balances
If your insurance requires a co-pay, this is due at the time of service. If there is a balance on your account from deductibles, coinsurance payments, or other unpaid services (same day cancel fee, no show fee, etc.) this must also be paid prior to your next appointment.
Non-Insurance Patients (Private Pay) or
Patients Who Fail to Provide Insurance Information are required to pay at time of service.
Payment and Collection Procedures
Statements will be sent to the patient for any unpaid balances and payment must be received within 10 days of receipt of the statement. If this is not possible, patient should contact the office to setup financial arrangements. If the balance is not paid within 90 days of receipt of the statement, and if no attempt to setup a financial arrangement has been made, the patient's account will be sent to our collection agency.
Minor Patients
The adults accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa, MasterCard, or payment by cash or check at the time of service has been verified.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
I have read and agree to the financial policies stated above that applies to me and I agree to the financial arrangements.
Consent to Release Information to Primary Care Physician
Communication between your psychiatrist/therapist and your primary care physician can be
important to help ensure that you receive comprehensive and quality health care. This information
may include diagnosis, treatment plans, progress and medication, if necessary. You may revoke this
consent at any time except to the extent that action has been taken in reliance upon it and that in an
event this consent shall expire two (2) years from the date of signature, unless another date is
specified.
If you are signing as a personal representative of an individual, please describe your legal authority to act for this
individual (power of attorney, healthcare surrogate, etc.)
Compliance Assurance Notification For Our Patients
The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient's consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you if you should choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this previously signed consent. If you have objections to this form, please ask to speak with our office manager. You may have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule”. We strive to achieve the very highest standards of ethics and integrity in performing services to our patients.
