New Client Information – Mid Towne

Date*

Who referred you to our practice?

Patient Name*

First Middle Last

Sex*

M
F

Date of Birth*

Social Security

Address*

Street Address Address Line 2 City State ZIP Code

Phone 1*

Home
Work
Cell

Phone 2

Home
Work
Cell

Patient's Employer*

Primary Care Physician or Psychiatrist*

Address or Phone*

Accounts must be kept current or statements will be mailed and calls will be made.
In the event that we need to contact you may we:

Leave a voicemail at the numbers above?*

Yes
No

Send mail to home?*

Yes
No

Leave our name and number with another person at the numbers above?*

Yes
No

Electronic Communication (Scheduling Only)

I authorize my clinician to contact me by email for appointment scheduling. I understand that 1) Email is not a secure method of communication; 2) Email will not be used for clinical questions, treatment discussions, or emergencies; and 3) I will notify my clinician if my email address changes.

Preferred Email Address:

FOR MINOR CHILDREN OR PATIENTS WITH GUARDIANS
(The parent/guardian who is bringing the child to the appointments will be listed as the responsible party. Please list that party’s name first)

Parent/Guardian #1

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact #1

Contact #2

Parent/Guardian #2

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Contact #1

Contact #2

Emergency Contact

Emergency Contact Name*

Relationship*

Phone*

Primary Insurance Company*

Name of Policy Holder*

Sex*

M
F

Relationship to Patient

Date of Birth*

Social Security

Contract/Member ID*

Group #*

Employer*

Secondary Insurance Company

Sex

M
F

Name of Policy Holder

Relationship to Patient

Date of Birth

Social Security

Contract/Member ID

Group #

Employer

All Copays and Deductibles are Due at Time of Service
INSURANCE RELEASE: I authorize the release of any information my clinician may feel is necessary to process my insurance claims. This may include information about my mental health. I authorize participating insurance payments directly to my provider. I fully understand that I will be responsible for any amounts due following a response from my insurance, including deductible and non-covered services. I understand that if I have an insurance the Psychology Associates does not participate with that I am responsible for payment in full at the time of service and a courtesy claim will be billed on my behalf and any reimbursement will be sent directly to me from my insurance company.

Electronic Signature of Patient/Parent/Guardian*

Date*

Psychology Associates Mid Towne
POLICY INFORMATION

Thank you for choosing Psychology Associates Mid Towne. We are committed to providing you with the highest quality, professional and ethical treatment. Please understand that payment of your bill is considered part of your treatment.
PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, OR VISA / MASTERCARD I DISCOVER / AMERICAN EXPRESS.

The following is Psychology Associate’s policy information, which we require you to read, Initial by checking the box next to each item, and electronically sign prior to any treatment. If you do not understand, or if you have any questions, please ask.

Confidentiality*

All information disclosed within sessions is confidential and may not be revealed to anyone without your expressed, written consent. There are exceptions to confidentiality. specifically IN CASES WHERE THE THERAPIST IS MANDATED BY LAW TO REPORT TO THE APPROPRIATE AUTHORITIES (i.e. WHERE THERE IS REASONABLE SUSPICION OF ABUSE OF CHILDREN. ELDERLY OR DISABLED PERSONS; WHERE THE CLIENT IS LIKELY TO HARM HIM/HERSELF OR OTHERS UNLESS PROTECTIVE MEASURES ARE TAKEN). If you have any questions about confidentiality, especially as it relates to children and adolescents, please ask your therapist. Please note that if you use insurance to help pay for your sessions, your signature on the bottom of our intake sheet grants the insurance company permission to request information about you from us.

Initial

Insurance*

We participate with several Insurance companies. Participation means that we will accept what your insurance company approves. You are responsible for any copays, deductibles or non-covered services at the time of service. If we do not participate with your insurance company you are responsible for the full fee at the time of service. We will tum in a courtesy claim for you to your insurance so that they can reimburse you directly, apply the visit to your deductible. etc.

Initial

Payment for Services*

Payment is expected at the time of the scheduled session unless you request other arrangements. If you are having diffiCUlty paying your bill please talk with us regarding payment arrangements. If we receive payment other than expected from your insurance company, the remaining balance will be transferred to your account. Any outstanding balance must be paid in full within 30 days. We will mail a statement to all clients who have a balance due on their account. If payment is not received within the calendar month, a $10 statement fee will be assessed. If an account remains unpaid, we will pursue collection of this past due account.

Initial

Minor Patients*

The adult accompanying a minor and/or the parents/guardians of the minor are responsible for full payment. For unaccompanied minors treatment will be denied unless charges have been pre-authorized to an approved credit card or payment is made by cash or check at time of service. unless prior arrangements have been made.

Initial

Building Policies*

Psychology Associates Mid Towne, located in the Women’s Health Center of West Michigan, has parking available in the attached Ellis parking structure. Please bring your parking ticket with you to your appointment and you will be given a parking voucher. You will need both the ticket and the voucher to exit the lot. Please note that this voucher will provide 1.5 hours of free parking for your time spent in our office. Without this voucher, you will be required to use a credit card payment to exit the ramp. There are fire alarm pull stations throughout the building. If a pull station is activated to create a false or nuisance alarm the fire department may assess a$1000 fine to the responsible party. Women’s Health Center of West Michigan is a smoke·free campus. This includes the building, the parking structure, and its surrounding property. Please dispose of your cigarettes, etc. before leaving your vehicle.

Initial

Cancellations / Missed Appointments*

We request that appointment cancellations be made 48 hours in advance. Cancellations made less than 24 hours prior to the appointment or no show appointments may result in a charge that may total the full fee of your appointment.

Initial

Client Acknowledgement and Agreement *I have read and understood the above information.
* I have had the opportunity to ask questions and have any questions answered.
* I agree to pay the fee for each visit for services rendered.

Electronic Signature of Patient or Responsible Party*

Date*

Electronic Signature Co-Responsible Party*

Date*

Notice of Privacy Practices Acknowledgement of Receipt

I acknowledge that I have been offered the Psychology Associates of Grand Rapids and Affiliated Therapists and Psychiatrists Notice of Privacy Practices.

Print Patient Name*

Patient or Patient Representative Electronic Signature*

Date*

Therapist's Name*

Psychology Associates Mid Towne POLICY INFORMATION

Notice of Privacy Practices Acknowledgement of Receipt

Psychology Associates Mid Towne
POLICY INFORMATION