Outpatient Wellness Clinic Patient Name: Date of Birth: Address: Phone: Email: Emergency Contact: Relationship: Phone: What is the reason for the appointment? Who were you referred by? (Physician, agency/ organization, friend, family member) If physician/agency/organization, please list name: Primary Care Physician: Have you previously received any type of mental health services (therapy, medication management, substance abuse treatment)? Yes No Briefly describe the treatment you received (i.e. inpatient hospitalization, therapy, family services, residential treatment): Please list ALL medications you are currently taking: Medication Name Dose Frequency Route (oral, injection)
Parents/legal guardians of children 17 years of age or younger, please complete: Is there a legal guardian other than a parent? Yes No Is there a court-ordered or legal custody arrangement? Yes No In cases where there is a legal guardian and/or custody arrangement that has been determined by the Court, you must provide Court documentation. Please initial one of the following: In case of an emergency my child may be accompanied by and/or released to the following people for his/her office visit(s)*: Name: Relationship: Phone: Name: Relationship: Phone: Name: Relationship: Phone: OR My child may ONLY be accompanied by and/or released to me, the parent(s) and/or guardian(s), for his/her office visit(s). *In the event that you would like to grant individuals other than yourself (the parent or legal guardian) the ability to make medical decisions about your child, a notarized document giving these individuals that right will be required in your absence. Parent or Legal Guardian Signature: Date: Relationship to patient: Patients 15 years of age or young must be accompanied by a parent/legal guardian to all outpatient wellness clinic visits. For patients 16 and 17 years of age, we highly recommend a parent/legal guardian be present for the initial appointment. We acknowledge that this is an inconvenience, but it is necessary to ensure the safety of your child and our staff.
Outpatient Wellness Clinic Appointment Policy Thank you for choosing Adventist Behavioral Health & Wellness Services as your health care provider. It is important that our patients have a clear understanding of our Appointment Policy. Please read the following, and sign the enclosed document stating you have read this information. If you have any questions or concerns, please let the front desk team know. Appointment Policy: Patients who need to reschedule or cancel their appointment are expected to call the front desk more than 24 hours before their appointment. Patients who do not call the front desk more than 24 hours before their appointment will be marked as a No Show, and are at risk of being charged a $30 administrative fee. After three (3) No Shows, the patient will be discharged from services. Patients who are late to their appointment may not be seen. Patients who are late on multiple occasions will be discharged from services.
Outpatient Wellness Clinic Appointment Policy Patient Name: Date of Birth: I have read the Outpatient Wellness Clinic Appointment Policy. Patient or Legal Guardian Signature: Date: Relationship to patient:
Statement of Financial Responsibility Thank you for choosing Adventist HealthCare Behavioral Health & Wellness Services for your healthcare needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies. Patient Financial Responsibilities: The patient (or patient s guardian, if a minor) is ultimately responsible for the payment for treatment and care. We will bill you insurance for you. However, the patient is required to provide the most correct and updated information regarding insurance. The Outpatient Wellness Clinic is a department of the Adventist Behavioral Health Hospital. Patients seen in a clinic or outpatient setting may receive separate bills for hospital and physician services. Your clinic or outpatient bill will include charges for the use of the facility and any tests or procedures done at the time of your appointment. Physician services will be billed separately by the billing agent for the physician, Key Medical billing service. Patients are responsible for payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Copays are due at the time of service. Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing. Patients may incur, and are responsible for payment of additional charges, if applicable. By my signature below, I understand that I am financially responsible for any and all charges not covered by my health insurer for services provided by Adventist Health Care Behavioral Health & Wellness Services. Signature Date Print Name
NOTICE OF PRIVACY PRACTICE UNDERSTANDING YOUR HEALTH RECORD INFORMATION Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future treatment. This information, referred to as your health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. YOUR HEALTH INFORMATION RIGHTS Unless otherwise required by law your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect and obtain a copy of your health record, obtain an accounting of disclosures of your health information, and request that your health information be shared with other physicians involved in your care. OUR RESPONSIBILITIES This organization is required to maintain the privacy of your health information. Please accept and review carefully this notice as to our legal duties and privacy practices with respect to your health information. This organization will abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change our Notice of Privacy Practice will be revised to reflect that change. We will not use or disclose your health information without your authorization, except as described in this notice. FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions and would like additional information, you may contact Kim Emerson at 240-238-1703. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATIONS We will use your health information for treatment. For example: Information obtained by a physician or our staff will be recorded in your record and used to determine the course of treatment that should work best for you. We will also provide your other physicians with copies of various reports that should assist them in treating you. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. We will use your health information for regular health operations. For example: In order to improve the quality and effective-ness of the healthcare and service we provide, the information in your health record may be reviewed.
Business Associates There may be some services provided in our organization through contracts with Business Associates. Examples include: physician services in the emergency room, radiology, pathology, laboratories, and our billing service. We may disclose health information to our Business Associate so they can perform the functions for which we have contracted them. We do require that they preserve the security of the information. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care, your location, and general condition. Communication with family: With respect to patients under the age of 16, the health professionals providing care, using their best judgment, may disclose to a family member, other relatives, close personal friends or any other person you identify, health information relevant to that person s involvement in your care or payment related to your care. With regard to minor patients age 16 years or older, without the consent of or over the express objection of the minor patient age 16 years or older, the health care providers or, on advice or direction of the health care provider, a member of the medical staff may, but need not, give a parent, guardian, or custodian of the minor patient age 16 years or older or the spouse of the parent information about treatment needed by the minor patient age 16 years or older or provided to the minor patient age 16 years or older. See, Md. Health Gen. Code Ann. Section 20-104 (c). Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties. Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation. Public health: As required by law, we may disclose health information to public health or legal authorities charged with tracking birth and deaths, as well as with preventing or controlling disease, injury, or disability. Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution, information necessary for your health and the health and safety of others. An inmate does not have the right to the Notice of Privacy Practices. We may disclose your records without your authorization in accordance with the provisions of Md. Health General Code Annotated Section 4-307. Complaints regarding our Privacy Practice can be made in writing to: Maryland Health Care Commission at 4160 Patterson Avenue, Baltimore, Maryland 21215 This notice will be prominently displayed in our office where registration occurs and our patients will be provided a hard copy. Effective: June 1, 2002
PATIENT CONSENT Patient Name: Date of Birth CONSENT FOR TREATMENT The undersigned authorizes Adventist Behavioral Health, its staff and physicians to render to the patient all customary care, therapy, treatment, tests and procedures considered advisable, including emergency treatment, dental and transportation to another facility if necessary. PRESCRIPTION HISTORY CONSENT The undersigned authorizes Adventist HealthCare Behavioral Health & Wellness Services to retrieve prescription history multiple or other unaffiliated medical providers, insurance companies and benefit managers and may be viewed by the providers and staff in the Outpatient Wellness Clinic, and may include prescriptions issued in past years. CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION It is our policy to take every measure to protect the privacy of your health information. However, your protected health information may be used and disclosed in order for us to carry out treatment, payment or health care operations. For our policies regarding the protection of your health care information, please refer to our Notice of Privacy Practice. It is your right to review our policies prior to signing this consent. The terms in the Notice of Privacy Practice may, at times, be revised and a current Notice will always be available in our office. As stated in our Notice of Privacy Practice, you have the right to restrict how we use your protected health information in order to carry out treatment, payment or health care operations, although we are not required to agree to these restrictions. If we do agree to these restrictions, the restriction will be binding on the provider. You have the right to revoke this consent in writing, except to the extent that we may have already taken action in reliance on it. TO BE COMPLETED BY PATIENT OR LEGAL GUARDIAN I acknowledge receipt of the Notice of Privacy Practice and consent to the disclosure of my health information for the purpose of treatment, payment and health care operations. Signed Date PAYMENT POLICY I certify that the information I have reported regarding my insurance coverage is correct and that any services not covered under my insurance plan will be my responsibility. I agree to promptly pay all charges when billed for medical services rendered and accept legal responsibility for any and all charges for the patient named above. Signed Date ASSIGNMENT OF BENEFITS I authorize Adventist Behavioral Health to apply for benefits on my behalf for the covered services rendered. I request that payment be made directly to the above-named provider, or in the case of Medicare Part B benefits and Medigap benefits, to myself or the party who accepts assignment. I permit a copy of the authorization to be used in place of the original. This authorization may be revoked, by either me or the above-named carrier, at any time in writing. Signed Date
Date: Authorization for Release of Information Patient Name: DOB: I hereby authorize the Adventist Behavioral Health & Wellness Services Outpatient Wellness Clinic to (check all that apply): Release Obtain The following information pertaining to behavioral or mental health services, drug and or alcohol diagnosis and treatment to/from: Name/Organization: Phone: Address: Fax : Information to be released check all that apply: Progress notes Psychiatric evaluation Treatment plan Medication list Verbal communication Laboratory reports Psychological evaluation History & Physical Other: Purpose of Disclosure: 1. I understand that this authorization is voluntary. 2. I understand that the patient s health care and payment will not be affected if I do not sign this form. 3. I understand that I may revoke this authorization in writing at any time except to the extent that Adventist HealthCare Behavioral Health & Wellness Services, or its employees or agents have acted upon this authorization. My written revocation must be submitted to the Outpatient Wellness Clinic. 4. I understand that if the organization authorized to receive this information is not a health plan or health care provider and if such information is re-disclosed by the recipient, the released information may no longer be protected by federal privacy regulations, but may be protected under Maryland law. 5. I understand that I may receive a copy of this form after I sign it and that I may inspect and request a copy of the information that I am authorizing for use/disclosure. This authorization will expire one year from today s date, unless otherwise specified here: Signature of Patient/Patient s Representative: Relationship to Patient: Print Name: Date: ----------------------------------------------------------------------------------------------------------------------------------- VERBAL Authorization for Release of Information (to be completed by OWC staff only): Name of person providing verbal release of information: Relationship to Patient: Date verbal release given: Adventist Behavioral Health & Wellness Services Staff Signature: Date: ***Signature of person providing release of information is to be obtained in the section above at next office visit ***