Patient Information

*ALL FIELDS NEEDED TO PROCESS CLAIM

Patient’s Name___________________________________________________________
* ADDRESS ______________________________________________________
            _____________________________________________  *ZIP ___________
*SOCIAL SECURITY NUMBER ______________________________________
Telephone (Home) ____________________________________
(Work) ____________________________________
(Cell) _____________________________________
* EMAIL ____________________________________________________________
*BIRTH DATE ___ / ___ / ___   Age ______ Sex ____ Marital Status _____________
If the client is a child, do you have custody/guardianship of the child?  Yes ____ No ____
Employed by ________________________________ Phone ______________________
Occupation ______________________________________________________________
Employer Address ________________________________________________________
_____________________________________________________
Spouse/Parent’s Name _____________________________________________________
Birth date ___ / ___ / ____  Age ______ Sex ___ Relation to client _________________
Social Security # ___________________________  Phone ________________________
Employed by _____________________________   Phone ________________________

*  These fields are MANDATORY in order for us to be HIPPA compliant.   In addition, it assists us in electronically processing your bill.  Clients who do not fill out these required fields will be listed as self pay.

Number of Children ______ Names and date of birth for each child :
_____________________________________________________

______________________________________________________

________________________________________________________

_____________________________________________________

Emergency Contact ____________________________ Phone _____________________
Name of Nearest Relative _______________________ Phone _____________________
Referred By _____________________________________________________________
Family Doctor ________________________________ Phone _____________________
Have you ever receive psychiatric services elsewhere?  Yes _______ No _______
If so, where? _____________________________________________________________
Medical Insurance Company ________________________________________________
Subscriber (name that appears on card) ______________________________________
* SUBSCRIBER’S DATE OF BIRTH  ____ / ___ / ___ * SS# __________________
Relation to Patient ________________________________________________________
ID Number _____________________________ Group Number ____________________
Person Responsible for Payment _____________________________________________
Is the patient covered by more than one insurance company? Yes ______ No _______
If so, with what company? _______________________________________________
Insurance Number of other Company ______________________________________
I, the undersigned, agree and accept financial responsibility for services rendered and consent to treatment.

_______________________________________________ date ___________________
client/parent/guardian signature

*  These fields are MANDATORY in order for us to be HIPPA compliant.   In addition, it assists us in electronically processing your bill.  Clients who do not fill out these required fields will be listed as self pay.

Middletown Counseling Patient Financial Policy

Patient’s Name ___________________________________________________________
Patient’s Date of Birth ____ / ____ / _______
Patient agrees to pay for all of their portions of service due in full at the time of service(s) provided by our office.

Any outstanding balances, co-payments, and deductibles are due prior to checking in for your appointments.

Patient Financial Class Policies
You are required to present a valid insurance card as needed through out your care. If there is a change in your insurance it is your responsibility to notify the front desk of that change.

Commercial Insurance Carriers
We bill most insurance carriers for you if proper paperwork is provided to us. Since your agreement with your insurance company is a private one, if your insurance carrier has not paid or paid less than you anticipated within 60 days of billing, fees are due and payable in full from you. 

Medicaid
Our office is a Medicaid provider and we will bill Medicaid for you. 

Worker’s Compensation
If your visit is work-related we will need the case number and carrier number prior to your visit in order to bill the worker’s compensation insurance company. 

Secondary Insurance
We do NOT bill secondary insurances unless they cross over automatically.  This applies to all secondary insurances.  As a courtesy we will provide you with a bill that you may submit to your secondary insurance.  It is your responsibility to pay whatever your secondary insurance would pay up front when services are provided.   

Methods of Payment
Our office accepts the following payment methods : cash, check, credit cards, debit cards, and patient financing options for those patients who are credit worthy. 

For returned checks we assess a $35.00 NSF charge.

If not paid according to terms, the patient understands that our office reports to an outside collection agency.  In the event that your account is turned over for collections, the patient agrees to pay all additional fees accessed in the collection of the debt.  Since your agreement with your insurance company is a private one, if your insurance carrier has not paid or paid less than you anticipated within 60 days of billing, fees are due and payable in full from you. 

I have read, understood, and agreed to the above terms and conditions.

Signature __________________________________________ Date ___________________

Limits of Patient Confidentiality

We are required to disclose confidential information if any of the following conditions exist :

• You are a danger to yourself or to others.
• You seek treatment to avoid detection or apprehension or enable to commit a crime.
• Your therapist was appointed by the courts to evaluate you.
• Your contact is for the purpose of determining your competence.
• Your contact is with your therapist is for the purpose of determining sanity in a criminal proceeding.
• The contact is one of which your psychotherapist must file a report to a public employer or as information required to be recorded in a pubic office, if such a report or record is open to public inspection. 
• You are under the age of 18 years and are the victim of a crime.
• You are a minor and your psychotherapist reasonably suspects you are the victim of child abuse.
• You are a person over the age of 65 and your psychotherapist believes you are the victim of physical abuse.  Your therapist may disclose information if you are the victim of emotional abuse as well. 
• You die and the communication is important to decide an issue concerning a deed or conveyance will or other writing executed by you affecting as interest in property. 
• You file suit against your therapist for breach of duty or your therapist files suit against you. 
• You have filed suit against anyone and have claimed mental/emotional damages as part of the suit.
• You waive your rights to privilege or give consent to limited disclosure by your therapist.
• Your insurance company paying for services has the right to review all records. 

Signature _____________________________________________ Date _____________

Release of Information

I authorize Middletown Counseling Services to contact my primary care physician ________________________  regarding an appointment being made for follow up, as well as information pertaining to psychological and emotional function. 

Signature _____________________________________________ Date _____________

Acknowledgement of Privacy and Security Policy

            I acknowledge that I have read a copy of the limits of Patient Confidentiality and understand my rights as they are discussed in that document.  I agree to allow Middletown Counseling Services to call me at home, my place of employment, mobile phone, or by email to change or confirm appointments, gather information , or to inform me of a problem.  I also agree to allow Middletown Counseling Services to leave messages pertaining to my involvement with my therapist on my answering machine.  I further agree to allow Middletown Counseling Services to use my name in the lobby area when informing me that my session is about to begin.
I understand that Middletown Counseling Services will notify me that I will be asked to sign a separate permission form if any medical or behavioral information is to be released to another organization or to a person not involved with my treatment with Middletown Counseling Services.  I understand that I have the right to refuse to allow this information to be released except where Middletown Counseling Services is required by law or contractual obligation. 

Signature _____________________________________________ Date _____________

Witness _____________________________________________ Date _____________

Please Read Carefully and Sign
Thank you for choosing Middletown Counseling Services.  Our goal is to provide high quality, thorough, and effective care for every client.  In an effort to provide services to as many individuals as possible in an efficient manner, we ask each client to accept their financial responsibility and adhere to the following conditions:

• You must give 24 hours notice before canceling an appointment. You will be charged a $25.00 fee for appointments that are cancelled with less that 24 hours notice.  You will be charged  a $35.00 fee for any appointments of which you do not show and do not provide notice.  These fees are not billable to your insurance company.
• Payment is expected at the time of service and can be paid in check, cash, or credit/debit card.  There will be a $35.00 fee for every returned check.  If your account becomes delinquent, the outstanding balance will be sent to a collection agency and you will be responsible for the collection fees.  
• A therapist can be contacted 24 hours a day for emergencies by calling 302-668-8582.  All phone calls longer than five minutes will be billed at the rate of $30.00 per 15 minutes or portion there of regardless of your therapy fee.  These fees are not billable to your insurance company. 
• If you have any questions, complaints, concerns, or compliments about your treatment or therapist, please contact Sandra Knauer, LCSW.
• There is a fee for preparation of reports and certain types of correspondence that are prepared outside of our regularly scheduled therapy sessions.  Such reports must be submitted in writing with a  $30.00 deposit .  There is also a fee for copies of records and record transfers.  A fee will be quoted after review of your written request. 
• I understand that my professional relationship with Middletown Counseling is protected by confidentiality.  I also understand that there are legal limits to confidentiality as in cases of suspected child abuse/neglect or when there is danger to self of others.  

I have read and understand the above information.  I also understand that my treatment at Middletown Counseling Services is contingent upon the above policies and I agree to abide by them.  I also understand that my treatment at Middletown Counseling Services is completely voluntary and I consent to treatment under the terms above.

Signature _______________________________________  Date ___________________

Printed Name ____________________________________________________________

Please Detach and Keep for Your Personal Use
Thank you for choosing Middletown Counseling Services.  Our goal is to provide high quality, thorough, and effective care for every client.  In an effort to provide services to as many individuals as possible in an efficient manner, we ask each client to accept their financial responsibility and adhere to the following conditions:

• You must give 24 hours notice before canceling an appointment. You will be charged a $25.00 fee for appointments that are cancelled with less that 24 hours notice.  You will be charged  a $35.00 fee for any appointments of which you do not show and do not provide notice.  These fees are not billable to your insurance company.
• Payment is expected at the time of service and can be paid in check, cash, or credit/debit card.  There will be a $35.00 fee for every returned check.  If your account becomes delinquent, the outstanding balance will be sent to a collection agency and you will be responsible for the collection fees.  
• A therapist can be contacted 24 hours a day for emergencies by calling 302-668-8582.  All phone calls longer than five minutes will be billed at the rate of $30.00 per 15 minutes or portion there of regardless of your therapy fee.  These fees are not billable to your insurance company. 
• If you have any questions, complaints, concerns, or compliments about your treatment or therapist, please contact Sandra Knauer, LCSW.
• There is a fee for preparation of reports and certain types of correspondence that are prepared outside of our regularly scheduled therapy sessions.  Such reports must be submitted in writing with a  $30.00 deposit .  There is also a fee for copies of records and record transfers.  A fee will be quoted after review of your written request. 
• I understand that my professional relationship with Middletown Counseling is protected by confidentiality.  I also understand that there are legal limits to confidentiality as in cases of suspected child abuse/neglect or when there is danger to self of others.  

I have read and understand the above information.  I also understand that my treatment at Middletown Counseling Services is contingent upon the above policies and I agree to abide by them.  I also understand that my treatment at Middletown Counseling Services is completely voluntary and I consent to treatment under the terms above.