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1 Barbara K. McEntee, Ph.D., PLLC 4815 S. Harvard Ave., Suite 470, Tulsa, Oklahoma Phone: Fax: Thank you for the opportunity to provide psychological services for you or your child. In working together, I will need to gather important information from you in preparation for our initial appointment. This packet provides important information about my services as well as forms that should be completed 48 hours prior to our appointment. For your convenience, a checklist of the necessary information from the packet is listed below: The following items in bold are required for every client. The items below that are not in bold print are needed from clients for whom the items are applicable. History Form Informed Consent Form/Receipt of Acknowledgement of PP Insurance Authorization Small Photo of Client or government ID (HIPPA requirement-identification purposes only) Copies of previous evaluations (psychological testing) Reports from occupational therapy or speech therapy School records and IEP documentation if applicable Child Custody Documentation or guardianship if client is a minor and parents are separated or divorced In the course of our work, I may request additional records and materials in order to provide a comprehensive assessment. Please do not hesitate to call if you have any questions or concerns. I look forward to working with you or your family member. Office Location: East side of Harvard Avenue just north of Interstate 44 in multi-story white building with Spirit Bank signage. There are no numbers on the building. Sincerely, Barbara McEntee, Ph.D. Clinical Psychologist Oklahoma License # 878

2 CONTACT INFORMATION Date Social Security # Chart # Client s First Name Last Name MI Telephone (Home) Work Cell Birthdate / / Age Gender F M Race Name of Parent/Guardian Phone Person Responsible for Payment Soc. Sec. # Signature of Person Responsible for Payment Emergency Information: Contact in case of emergency Name Relationship Phone Physician Phone Current Medications Allergies Employment Information (if client is a child, use parent s employment) Client/Guardian: Place Phone Hrs Spouse: Place Phone Hrs Referral Source: How did you hear of my office (or from whom) Phone Relationship to referral source: Contact Information: Please indicate preferred method of contact Telephone: Mail: (password protected)

3 INSURANCE AUTHORIZATION I authorize Barbara K. McEntee, Ph.D., PLLC, to release my protected (PHI) necessary to process insurance claims, which includes without limitation, the client s name, date of birth, diagnoses and services, as well as the insured s name, date of birth, and social security number. I understand that at times insurance companies require the release of progress notes, reports, or letters from the psychologist to justify or explain services and diagnoses. I authorize payment of benefits to Barbara K. McEntee, Ph.D., PLLC. Signature of Client/Parent/Guardian Date

4 Appointment Reminders Client Name Date of Birth: You can receive an appointment reminder to your address, cell phone via a text message, or your home phone via a computer generated voice message two days before your scheduled appointments. How would you like to receive appointment reminders? Please check one: Via a text message on my cell phone (normal text message rates will apply) Cell Phone Number: Your cell phone company (circle one): Alltell AT&T Boost Mobile Nextel Sprint SunCom T-mobile US Cellular Verizon Voice Stream Virgin Mobile Other Via an message to this address: An automated system sends the s reminders Vis automated telephone message to this phone # None of the above. I will remember my appointment on my own. (Missed appointment fees will still apply) Appointment information is considered to be Protected Health Information under HIPPA. In my signature, I am waiving my right to keep this information completely private, and requesting that it be handled as I have noted above. Signature Date

5 Barbara K. McEntee, Ph.D., PLLC NOTICE OF PRIVACY POLICIES It is my duty as a psychologist to protect your health information and follow state and federal laws governing the use and release of this protected health information (PHI). This notice describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information. A client s rights: You have the right to request a review or receive your medical files by requesting a copy of your records in writing with an original signature. If your request is denied, an explanation of the denial will be provided to the client. For non-emancipated minors, records may be requested by the custodial parents or legal guardians. In the event of a client s death, the spouse or parents have the right to access the client s records. Often, a release of information is requested by professionals, and you have the right to cancel a release of information by providing a written notice to this psychologist. If information is to be sent to another location, this request must be in writing. Also, you have the right to restrict which information might be disclosed to others. However, the psychologist is not bound to follow this request if he or she does not agree with the restrictions. The client has the right to request that any information about the client be communicated by other means or to another location, which requires a written request. When my office must contact the client, efforts are made to conserve confidentiality. Notify my office in writing how we can reach you and how you want me to identify myself. The client has the right to disagree with the medical records in this psychologist s file and may request that the information be changed. However, this psychologist can deny the request to change the records, and the client has a right to make a written statement about the disagreement to be included in the file. As the client, you have the right to know what information in your record has been provided and to whom, with a written request. Also, you will be given a written copy of this notice. A psychologist s legal duties and privacy practices: As a psychologist, state and federal laws require that I keep your medical records private and provide a notice informing you of this privacy of information policies, your rights, and my duties. I am required to abide by these policies until replaced or revised. This psychologist has the right to revise privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place. Your protected health information may be used and provided to others by this psychologist for treatment, payment, and operational needs. With your written consent, I may share your health information with colleagues for consultation, health care providers who provide you with treatment such as doctors and nurses, mental health professionals, or business associates affiliated with my office such as billing, training, and audits. When information is shared with a business associate in my office, this psychologist requires the same level of privacy and security from that associate. This psychologist may give information about you to your health plan or health insurance carrier to obtain eligibility and benefits for your plan, to request payment for services already provided, or to request preauthorization for planned services. Information may also be shared with a collections agency or small claims court in the case of nonpayment.

6 In order to provide the highest level of quality care and appropriate services, your health information is considered private information. Information may be shared with another party, but verbal and written records will not be shared without the written consent of the client or legal guardian. However, there are emergency situations or exceptions in which client information can be disclosed to others without written consent. When a client discloses intentions or plans to harm himself or another person, the psychologist is required to report this information to legal authorities and seek hospitalization if necessary for the client and make reasonable attempts to notify the family of the threat to safety. Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker s compensation laws. Health care professionals are required to release records of clients when a court order has been placed. If a client reports that he or she is abusing a child or vulnerable adult or a child or vulnerable adult is in danger of legal authorities. If a client is the victim of abuse, negligence, violence or crime and safety appears to be at risk, this information may be shared with law enforcement officials to prevent future occurrences. When a client has admitted prenatal exposure to controlled substances that are potentially harmful, the health care professional is required to report this information. This psychologist may provide information to law enforcement officials, applicable to federal and state laws and regulations, for purposes that are required by law or in response to a court order signed by a judge. For clients involved in lawsuits and disputes, health information may be provided in response to a court order. Additionally, health information may be released to a coroner, medical examiner, and funeral director as necessary to carry out duties as authorized by law. For organ donors, health information may be provided to an organization that procures, banks, or transports organs for the purpose of an organ, eye, or tissue donation and transplantation. For a veteran or current member of the armed forces, health information may be released when required by military command or veteran administration authorities. This psychologist will give health information about you when required to do so by federal, state, or local law. If you have any complaints or questions regarding these procedures, you should contact this psychologist and discuss these issues in a timely manner. In addition, you may submit a complaint to the U.S. Dept. of Health and Human Services and the Oklahoma State Board of Examiners of Psychologists. There is no punishment for filing a complaint. Acknowledgement for Receipt of Privacy Practices I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications. My signature indicates that I have received or been offered a copy of the office s privacy practices. Client s Name (please print Signature Date Signed by client parent 000 guardian other personal representative Barbara K. McEntee, Ph.D., Clinical Psychologist, OK License #878 Rev: