INTAKE REGISTRATION FORM Therapist: of Appt: File Created Practice Fusion: Discovering new choices together File Created Kareo: Today s : PCP: CLIENT INFORMATION Last Name First M.I. D.O.B Marital Status Street address P.O. Box SS # City State Zip Phone Number Alternate Contact # Age Gender Male Female ( ) Email Address Referred by N/A Court Parole/Probation TANF CPS Physician Victims of Crime Other Please Specify: Name of Physician/Case Worker/Probation Officer Phone Number ( ) Primary Insurance INSURANCE INFORMATION (Please give your insurance card and ID to the Front Desk Clerk. Thank you. Phone Number Group Number ( ) Policy Number Subscriber s Name Subscriber s S.S. # D.O.B. Employer Client s Relationship to Subscriber Self Spouse Child Other Please Specify: Secondary Insurance (if applicable) Phone Number ( ) Group Number Policy Number Subscriber s Name Subscriber s S.S. # D.O.B. Employer Client s Relationship to Subscriber Self Spouse Child Other Please Specify: PARENT/GUARDIAN INFORMATION (Please complete if client is under 18 years of age) Parent/Guardian Name D.O.B. Phone Number ( ) Name of Local Friend or Relative (Not living at the same address) EMERGENCY CONTACT Relationship to Client Phone Number ( ) CONSENT The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider HeadsUp Guidance and Wellness Centers of Nevada. I understand that I am financially responsible for any balance. I also authorize HeadsUp Guidance and Wellness Centers of Nevada or my insurance company to release any information required to check for eligibility or process my claims. Client/Guardian Signature 702-922-7015 PHONE ~ 702-922-6600 FAX INTAKE FORM MARCH, 2013
Office Policies Insurance Reimbursement: Patients who carry insurance will be notified at the time of registration or as soon as possible thereafter whether we accept your specific insurance. Cancellation: Since an appointment reserves time specifically for you, a minimum of 24- hours notice is required for rescheduling or cancelling an appointment. If you miss or late cancel 3 or more appointments without providing appropriate notice as described above, you will no longer be able to schedule appointments. You will be notified by letter at the address we have on file should this occur. You can still be seen on a walk- in basis any time during regular business hours. We will do our best to accommodate you should this happen; however, you will no longer be guaranteed your usual therapist. Please understand that you may have to wait to see the first available therapist. Office Hours: Our office hours are from 9:00 am to 5:00 pm Monday through Friday. Saturday appointments are available upon request. We are closed on Sundays and holidays. If you need to reach us between sessions, please call the office number. If you call after hours, you will be directed to our answering service where you can leave a message for us and we will return your call as soon as possible. Emergency Procedure: An emergency is an unexpected event that requires immediate attention. If an emergency situation arises, please state this to the answering service or staff member answering the phone and we will return your call as soon as possible. In a life- threatening emergency, please dial 9-1- 1. If your situation is not life threatening and we do not get back to you within 60 minutes and the emergency persists or requires it, please call your physician or go to the nearest emergency room for treatment. I have read and understand the office policies as outlined above. Client Signature Parent/Guardian Signature TREATMENT CONTRACT/INFORMED CONSENT MARCH, 2013
Treatment Contact and Informed Consent The Treatment Process: Participating in psychotherapy can result in a number of benefits to you, including a better understanding of your personal goals and values, improved psychosocial adjustments and resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, but more often it will be slow and frustrating. Remembering and resolving significant life events in therapy can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also lead to discomfort and may result in changes that were not originally intended. As part of our therapeutic process, we may use several techniques including hypnosis, neuro- linguistic programming (NLP), cognitive behavioral therapies (CBT) among others. We will adapt your treatment to your particular condition and may utilize a combination of treatment modalities to ensure overall effectiveness. As each therapist has an array of tools and techniques that may assist you, feel free to discuss your therapists specialties and treatment concentrations. Client s Rights: You have the right to a confidential relationship with your therapist. Within certain legal limits (see #4 below), information revealed by you during the course of therapy will be kept completely confidential and will not be revealed to any person without your written permission. 1. You have the right to know the content of your records at any time and we have the right to provide you with the complete record or a summary of their content. You may obtain copies at $.45 per page. 2. If you ask us, we can release any part of your records on file to any person you specify. We will tell you whether we think releasing that information to that agency or person may be harmful to you. 3. If you participate in couples or family counseling sessions, you understand that all information shared in a joint session is open to all participants. Any information shared in an individual session is kept confidential and separate from joint sessions. This separate information is not open to any other member of the couple/family through the counselor or case documentation in the chart. 4. Under certain legally defined situations, we have the duty to reveal information you tell us during the course of therapy to other persons without your written consent. We are not required to inform you of our actions if this occurs. These legally defined situations include: a. If you reveal to us active child abuse, neglect, or abduction. An alleged perpetrator is in contact with minors and there is reasonable suspicion that he or she may still be abusing minors. If active physical abuse of a dependent adult or an elder is taking place. b. If you seriously threaten harm or death to another person, we are required to warn the intended victim and notify the appropriate law enforcement agencies. c. If you seriously threaten harm or death to yourself or we assess that you are unable to meet your basic needs for food, clothing, and shelter due to grave disability, we are required to provide for your safety and notify the appropriate authorities.
d. If you are in therapy or are being treated/tested by the order of the court, the results of the treatment or tests ordered must be revealed to that court. e. If a court of law issues a legitimate subpoena, I am required by law to provide the information specifically described in that subpoena. f. If you are in a lawsuit claiming emotional harm, the opposing side may subpoena your therapy records. 6. You have the right to ask questions about any of the procedures used in the course of your therapy. 7. Should you choose not to enter therapy with us, we will provide you with names of other qualified professionals whose services you might prefer. 8. You have the right to terminate therapy at any time, unless under a court order, without any financial, legal, or moral obligations other than those you ve already incurred. We have the right to terminate therapy with you under the following conditions: a. When we believe that therapy is no longer beneficial to you. b. When you fail to follow recommended treatment. c. When we believe that another professional will better serve you. d. When you have failed to show up to your last two therapy sessions without 24 hour notice. e. If we determine during the first three sessions that we cannot help you, we will assist you in finding someone qualified. If we have written consent, we will provide that professional with the information they request. If any of these situations apply, we will send you a certified letter to your address of record to inform you of our decision and we will give you the names of several therapists for your future counseling needs. As life can bring unexpected circumstances, should any one of us be unable to continue your therapy, our Clinical Director will contact you to discuss what would be best for you at that time.
Consent for Treatment I/we, authorize and request that HeadsUp Guidance and Wellness Centers of Nevada carry out psychotherapeutic examinations, diagnostic procedures, and/or treatment which now or during the course of my care as a client are advisable. I/we consent to take part in treatment with Marriage Family Interns and/or practicum students. I/we understand that in accordance with the standard policies of HeadsUp Guidance and Wellness Centers of Nevada all cases are staffed under clinical and administrative supervision, and other qualified supervisors for the purpose of ensuring the best client care possible. The content of staffing is held confidential. I/we understand that the purpose of any procedure will be explained to me and be subject to my agreement. I have read and fully understand this Consent for Treatment form. Client Name (Please print) Client Signature Parent/Guardian Signature
Notice of Privacy Practices Effective : August 18, 2008 Revised : March 1, 2013 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I. Who Will Comply With This Notice? This notice will be followed by MCO Legacy, LLC,. d/b/a HeadsUp Guidance and Wellness Centers of Nevada. II. Our Commitment Regarding Your Confidential Health Information In order to provide you with the highest quality of care and to comply with various laws, we maintain a record of the services you receive from us. Your record contains personal information regarding your health care and payment for your health care. We understand that your health information is personal, and we are fully committed to protecting and enforcing your privacy rights. This notice outlines our obligations with regard to using or disclosing your confidential health information and describes your rights to access such information. By law, we are required to ensure that your confidential health information remains private. We also are required to provide you with a copy of this notice and comply with the terms of the notice that is currently in effect. III. How We May Use or Disclose Your Confidential Health Information A. For Treatment We may use or disclose your confidential health information to provide you with health care treatment or services. For example, physicians, physician s assistants, therapists, counselors, nurses, or other clinical staff members will record information in your medical record to diagnose your condition and determine the best course of treatment for you. Those individuals will work to provide you with the highest quality of care. We also may provide other health care professionals or subsequent health care providers with a copy of your medical records to assist them in treating you after you leave our care. B. For Payment We may use or disclose your confidential health information so that we may bill for services rendered and collect payment from you, an insurance company, or a third party, such as Medicare or Medicaid or an employee assistance program. For example, we may send a bill to your health plan, such as a health insurer, which may include information that identifies you, your diagnosis, treatments received, and supplies utilized. We also may tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine your eligibility to receive the treatment. C. For Health Care Operations We may use or disclose your confidential health information for the operations of our health care businesses. For example, clinicians, risk management staff, and members of our quality assurance teams may use your health information to evaluate the care and outcomes you received, as well as to assess the competency of our caregivers. Our health care operations are aimed at continually improving the quality and effectiveness of the health care and services we provide. D. For Appointment Reminders and Treatment Alternatives We may contact you for appointment reminders or to tell you about possible treatment options, alternatives, health- related benefits, or other services that may be of interest to you. E. To Prevent a Threat to Health, Safety, or Welfare We may disclose your confidential health information to the appropriate authorities if, in our professional or clinical judgment, we believe you are the victim of abuse, neglect, domestic violence, or other crimes, or to avert a threat to the health and safety of you or others. NOTICE OF PRIVACY PRACTICES MARCH, 2013
F. To Our Business Associates We receive some services through contracts with third- party business associates. For example, we may utilize outside vendors to provide medical transcription or billing collection services. When we use such services, we may disclose your confidential health information to the business associates so that they can perform the functions on our behalf. To protect your privacy rights, we contractually require that the business associates appropriately safeguard your confidential information. G. For Use in a Facility Directory or Census Report We may use your name, location in our facility, and general condition for an internal directory, census report, or similar patient- listing purposes. H. For Communications With Your Family or Caregivers Unless you provide us with a written objection, we may, in our best professional judgment, disclose your confidential health information to a family member or caregiver, if such information is relevant to that person s direct involvement in your care or payment for your care. Such disclosures may be made to your family member, legal guardian, another relative, personal friend, or any other individual you identify to us. I. For Research Purposes We may disclose your confidential health information to researchers when an institutional review board has approved their research. The institutional review board will have reviewed the research proposal and established protocols to ensure the privacy of your health information. J. In Lawsuits and Legal Disputes If you are involved in a lawsuit or other legal dispute, we may disclose your confidential health information in response to an order of a court or tribunal. We may also disclose your confidential health information in response to a subpoena, warrant, discovery request, or other similar legal process by someone else involved in the matter, though we will attempt to obtain your written authorization prior to doing so. K. To Funeral Directors or Coroners We may disclose your confidential health information to funeral directors or coroners, consistent with applicable laws, in order to enable them to carry out their duties, such as identifying a deceased individual or determining a cause of death. L. To the Food and Drug Administration (FDA) We may disclose your confidential health information to the FDA, if such disclosure is related to adverse effects or events with respect to food, drugs, supplements, products or product defects, or post- marketing surveillance information to enable product recalls, repairs, or replacement. M. To Workers Compensation Agencies We may disclose your confidential health information, consistent with applicable laws, when necessary to comply with laws relating to workers compensation or other similar employment- related programs established by law. N. For Health Oversight Activities We may disclose your confidential health information to health oversight agencies for authorized activities, which may include audits, investigations, and inspections related to our licensure, insurance, and accreditation status. These activities monitor compliance with government programs, contractual agreements, licensure and accreditation standards, and laws and regulations. O. To the U.S. Department of Health and Human Services (DHHS) We must disclose your confidential health information to DHHS upon request, as necessary to determine our compliance with the government s standards and regulations. P. For Matters of Public Health We may disclose your confidential health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Such cases may include disclosures necessary to prevent or control diseases, to report possible abuse or neglect, or to notify individuals of product defects and recalls. NOTICE OF PRIVACY PRACTICES MARCH, 2013
Q. To Correctional Institutions If you are an inmate of a correctional institution or are under the custody of a law enforcement agency, we may disclose your confidential health information to the institution when necessary for your health or the health and safety of others. R. For Law Enforcement Purposes We may disclose your confidential health information for law enforcement purposes, including in response to a court order, subpoena, warrant, or other similar legal process, to identify or locate a suspect, fugitive, material witness, to report criminal conduct at our facility, or to report an injury or death we believe might have been a result of criminal activity. S. To Authorities for Military, National Security or Intelligence Purposes We may disclose your confidential health information, if required, to military authorities or federal officials for authorized activities related to military, intelligence, counter- intelligence, or other national security matters. T. Other Uses and Disclosures Not Described Above For all other uses and disclosures, the facility will obtain your prior written authorization. You have the right to revoke such authorizations, pursuant to the terms found on the facility s authorization form. IV. Your Rights With respect to your confidential health information, you have the following rights: A. Right to Inspect and Copy You have the right to inspect and have copied your confidential health information. To inspect and copy your confidential health information, you must submit your request in writing to the facility s Medical Records Department. If you request a copy of the information, we may charge a reasonable cost- based fee for the copying and mailing per your request. Subject to applicable laws, we may deny your request to inspect and copy if, in our professional judgment, we determine that it would be detrimental to your care or otherwise harmful to you or others or if denial is permissible under other applicable laws. B. Right to Request an Amendment If you feel your confidential health information is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing to the facility s Medical Records Department. In addition, you must provide a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing, does not include a reason to support the request, if it would be detrimental for your care or otherwise harmful to you or others, or if the information is correct and complete. The facility s clinical supervisor will review all such requests. C. Right to Accounting of Disclosures You have the right to request a list of accounting for disclosures of your confidential health information that we made. To request this accounting of disclosures, you must submit your request in writing to the facility s Medical Records Department. Your request must state a specific time period for when the disclosures were made. We will provide you with the accounting in the manner you designate in writing, or notify you of the reasons why we are unable to provide such accounting. Please be aware that we will not provide an accounting of all disclosures that were made, such as those disclosures made (a) prior to April 14, 2003; (b) for treatment purposes; (c) for payment purposes; (d) for health care operations; (e) pursuant to your written authorization; or, (f) as part of the facility s directory or census reports. D. Right to Request Restrictions You have the right to request a restriction or limitation on the way we use or disclose your confidential health information. Your request must be submitted in writing to the facility s Medical Records Department, and it must state the specific information you want restricted and how you want the restriction to occur. We are not required to agree to your request for restrictions if it is not feasible for us to comply, if we believe it will negatively impact the care we provide you, or if the restriction will prevent us from providing emergency treatment. If we do agree, we will comply with your request. The facility s clinical supervisor will review all such requests. E. Right to Request Confidential Communications You have the right to request that we provide confidential communications to you. You may ask us to share information with you in a manner or location of your choice. For example, you could request that we send your information to an address other NOTICE OF PRIVACY PRACTICES MARCH, 2013
than your home address or that all communications be made via mail. To request confidential communications, you must make your request in writing to the facility s Medical Records Department. You do not need to provide reasons for your request, and we will attempt to accommodate all reasonable requests. F. Right to Obtain a Paper Copy of This Notice You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please submit a written request to the facility s Medical Records Department. Please be aware that this notice is available and posted at all of our facilities and on the facilities web sites. V. Changes to This Notice We reserve the right to modify the provisions of this notice and to make the new notice effective for all confidential health information we maintain prior to the effective date of the new notice. If we modify this notice, we will post the new notice in If our you facilities want more and on information our facilities about web our sites. privacy practices, have questions or concerns, or would like to file a privacy complaint, you may contact our Corporate Compliance Officer at (702) 922-7015. You also may submit a complaint to the Office VI. Questions of Civil Rights or Complaints (OCR) of the DHHS. We will not retaliate against you in any way if you choose to file a complaint about our privacy If you want practices, more information nor will it affect about your our rights privacy or practices, status as a have patient questions with us. or concerns, or would like to file a privacy complaint, you may contact our Corporate Compliance Officer at (702) 922-7015. You also may submit a complaint to the Office of Civil Rights (OCR) of the DHHS. We will not retaliate against you in any way if you choose to file a complaint about our privacy practices, nor will it affect your rights or status as a patient with us. NOTICE OF PRIVACY PRACTICES MARCH, 2013
NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT HeadsUp Guidance and Wellness Centers of Nevada is required by law to maintain the privacy of their patients. Your protected health information will be used or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day to day health care operations of this practice. You should review the Notice of Privacy Practices above for a more complete description of how your protected health information may be used or disclosed. HeadsUp Guidance and Wellness Centers of Nevada reserves the right to modify the privacy practices outlined in the notice. AUTHORIZED PERSONS TO RECEIVE DISCLOSED INFORMATION: (This person(s) may contact HeadsUp Guidance and Wellness Centers of Nevada and receive verbal information about the patient.) Name : (Person authorized to receive information) Relationship to Patient: I have read the Notice of Privacy Practices and give my permission to HeadsUp Guidance and Wellness Centers of Nevada to use and disclose my health information in accordance with it. Name of Patient (Print) Name Signature of Patient of Patient/Patient (Print) Representative/Relationship to Patient Signature of Patient/Patient Representative/Relationship to Patient NOTICE OF PRIVACY PRACTICES MARCH, 2013
Assignment and Release I certify that I and/or my dependents have the insurance coverage listed on the intake registration form and assign directly to HeadsUp Guidance and Wellness Centers of Nevada all insurance benefits otherwise payable to me for services rendered. I authorize use of my signature on all insurance submissions. I understand that I must pay copayments, deductible fees, and self- pay fees prior to each consultation in order to receive services. If I cannot provide payment, I understand that I must notify HeadsUp Guidance and Wellness Centers of Nevada to receive further instructions. I understand that my insurance is a contract between my insurance carrier and myself. I understand that HeadsUp Guidance and Wellness Centers of Nevada will help file my insurance claims but CANNOT guarantee that insurance will pay my claim. I understand that I am financially responsible for all charges whether paid by my insurance or not. I understand that HeadsUp Guidance and Wellness Centers of Nevada will not enter into a dispute with my insurance carrier over the claim. HeadsUp Guidance and Wellness Centers of Nevada may use my health care information and may disclose such information to my insurance companies and their agents for the purpose of obtaining payment for services and authorizations, and to determine insurance benefits. My signature below indicates that I have read and understand this release. Client Signature Parent/Guardian Signature TREATMENT CONTRACT/INFORMED CONSENT MARCH, 2013
Authorization to Release Confidential Information I authorize HeadsUp Guidance and Wellness Centers of Nevada to release information to the person(s)/organization(s) listed below: School/Organizations/Medical Provider Phone Number Fax Number Address City State/Zip I authorize HeadsUp Guidance and Wellness Centers of Nevada to obtain information from the person(s)/organization(s) listed below: School/Organizations/Medical Provider Phone Number Fax Number Address City State/Zip Client Name: DOB: Provider: Parent/Guardian Name: Address: City: State/Zip: Specific Information to be released: Identifying Information Medical Information Therapy Notes Billing Records Phone Consults Diagnostic Information Complete Medical Record Substance Information Other: I authorize the release of these records through facsimile and/or email. I understand and agree that should the records be in advertently transmitted to an unauthorized recipient, through no fault of the sender, I hereby waive any claim against the sender and agree to hold the sender harmless from any and all responsibility for damages, if any, arising from the faulty transmission. This authorization is in effect until termination of treatment or 12 months from the date below. I understand that I many change my mind at any time and revoke this authorization by notifying HeadsUp Guidance and Wellness Centers of Nevada in writing. I understand that changing my mind or refusing to sign this form will not affect my treatment. I understand that I have the right to inspect or copy any information disclosed under this authorization. I understand that once my health information is disclosed to the recipient, HeadsUp Guidance and Wellness Centers of Nevada cannot guarantee that the recipient will not disclose the health information to a third party or as required by law. I have read and understand this authorization and had a chance to ask questions about the disclosure of health information. I authorize HeadsUp Guidance and Wellness Centers of Nevada to disclose any health information in the manner described above. Client Signature: : Parent/Guardian Signature: (if patient is minor) : 702-922-7015 PHONE ~ 702-922-6600 FAX AUTH TO RELEASE APRIL, 2013