Intake Form

Donna C. Wilson, Ed.D., Psychologist

Confidential Information

Patient was referred by:

Patient Information:

Name:

Date Of Birth:

Age:

Sex:

Education:

Home Address:

City:   State:   Zip:

Email:

Phone:  Text to:

Social Security Number:

Presenting Problem:

Patient Interests:

Medical Issues/Medications:

Policy Holder Information:

Name:

Date Of Birth:

Age:

Sex:

Education:

Home Address:

City:   State:   Zip:

Email:

Phone:  Text to:

Social Security Number:

Employer:

Employer Address:

City:   State:   Zip:

Insurance Information:

Insurance Name:

ID#:

Group #:

Insurance Address:

City:   State:   Zip:

Provider Verification Phone Number:

Deductible:  Met?:

Pre-authorization Number:

Please feel free to ask questions about the following:

Payment/InsuranceAgreement

I accept responsibility for payment of charges for services rendered to the above named patient.  I understand that full payment and/or my co-payment and/or deductibles are expected at the time services are rendered.  Dr. Wilson requires co-payment in cash.  I understand that, unless the above named patient has coverage under a managed health plan (e.g., HMO, PPO, EAP, etc.) to which I subscribe and in which the doctor is a participating provider, I am personally responsible for the payment of all charges.  I understand that, as a courtesy, the provider will file insurance claims however this does not release me of my responsibility for payment of the charges for services.  Payment for any charges denied or not covered by my insurance company becomes my responsibility and I agree to pay these charges.  I also understand that any court order I have is an agreement between me and the courts, NOT the provider and I am still responsible for payment of all charges.  In addition, if I have requested that the provider file the charges to my insurance company, I understand that securing benefits under health insurance or other health plans will require that the provider will provide the insurance company with confidential patient information, including diagnosis and the dates and type of service rendered.  I acknowledge that many plans require an initial precertification of care before I can use my insurance benefits.  It is my responsibility to make sure precertification requirements are met by me if I elect to use my insurance benefits.  Further, I understand that for utilization review, quality assurance, and other claims review purposes, it may sometimes be necessary for the provider to provide the insurance company with additional information concerning case history, presenting problems, treatment plans, prognosis, and other case information.  I fully and freely consent to the release of any and all such patient information as is necessary for the processing and review of health care claims made by or on behalf of the above named patient. This consent shall remain in effect until all claims have been fully processed and all review procedures completed. 

 

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Signature of adult patient or parent/legal guardian of patient less than 18 years of age        Date

 

 

NOTIFICATION OFPATIENT RIGHTS -- HIPPA

In filing your insurance claim for you, it is understood that you are granting me permission to reveal confidential information such as the dates you are seen, the length of the appointment, and your diagnosis.  This type of information is required by your carrier if you want insurance to pay your claim.  Additionally, almost all companies now require further utilization review to submit a more extensive report documenting the clinical and medical necessity for your carrier.  Many carriers will require auditing/review of your records for every visit.  The compromising of your confidentiality is standard in today's marketplace whenever one elects to use third party insurance coverage for services rendered.  Fortunately, the newly enacted HIPAA regulations do provide you an increased degree of privacy and confidentiality regarding your protected health information.  Payers of care can no longer make full release of all your mental health record a condition for payment of your claims.  Instead, I will be able to limit release of your mental health record to only your designated mental health record set and not my psychotherapy notes of our sessions together.  As explained in Notification of Patient Rights Document the designated mental health record is limited to the following examination, your comprehensive treatment plan, progress notes, any reports of clinical summaries, any correspondence with outside parties you authorized me to release, and any utilization review reports which have occurred regarding your care.  Licensed psychologists have a strong privileged communication law in our state which carries the same legal status as that of attorney-client.  What you talk about in your established relationship with me is protected by privileged communication laws and confidentiality principles, with the exception of certain specific actions (i.e. clear and imminent danger to self and/or others, suspected child abuse, worker's compensation related cases, if your psychiatric or psychological health becomes an issue in a lawsuit, whatever information is shared in utilization review reports for authorization of care, compliance with chart audits by your insurance carrier).  With these exceptions, unless you specifically sign a release of information authorizing me to talk to someone, all communications are kept private, confidential, and privileged.  I strive to maintain privacy of your confidential communications with me.

 

Your Informed Consent to Care:

 

I have provided this information to you in the hope of fully informing you about the policies of my office and some of the parameters of care you will receive here, such as the importance of confidentiality. Psychiatric and psychological care, like other things in life, offer no absolute guarantee of success and there are limitations to any form of care offered a patient.  Since such limitations are always a function of the particular problem in question, I invite you to discuss your treatment plan with me.  After we have met to discuss your concerns, I will construct an individualized treatment plan and share it with you so that you and I have our plan for what problems we are going to solve and how.

 

Please feel free to discuss any of these matters with me in more detail.  By signing below, you acknowledge having read, understood, and agreeing to these policies and procedures.  Your signature acknowledges your informed consent for care. 

 

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Signature of adult patient or parent/legal guardian of patient less than 18 years of age      Date

 

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Witness


 Patient Agreement with Policies and Procedures

Donna C. Wilson, Ed.D.,Psychologist

Welcome to my practice!

The following information is provided to my patients to assist you in understanding policies and procedures at my office.  I strive to provide you care which is both comfortable and of the highest quality.  Please do not hesitate to ask questions of me at any time about these matters.

The previous page is the Notification of Patient Rights document now required with the passage of the federal "medical records privacy law" known as HIPAA (Health Insurance Portability and Accountability Act).  I am required by law to inform you of your rights and secure your signature indicating you have received the HIPPA information.  Laws such as these are important, but also complex and in my Notification of Patient Rights document I have tried to inform you about your rights in plain, simple language. Please read the contract and do not hesitate to ask me any questions you might have about these matters. 

 

Appointments:

I typically schedule my own appointments for patients but sometimes a clerical staff person will do so when appointment changes come to pass.

Since patients are seen by appointment only, the appointment time given is reserved for you.  Dr. Wilson's cancellation policy is that a no show will result in the case being closed.  A late cancellation without an emergency will result in the case being closed.  Dr. Wilson will transition any closed case to another provider at the request of the patient.   

Emergencies and Telephone Calls:

While you will be seen at a reserved time which fits your schedule, there may be occasions when you need to talk to me between appointments.  I will return your call as promptly as I can.  Please understand that the duration of non-emergency phone calls is limited to only a few minutes and may be followed up during your next therapy session.  If your call is a potential life threatening emergency, you should declare your call to be an emergency and call 911. 

 

Fees and Payments:

My fee is $200 per a 45 minute session.*  I will file third party insurance forms for you, if you so desire.  Co-payments, and deductibles are due (in cash) at the time services are rendered.  Payment for any charges denied or not covered by your insurance company becomes your responsibility.  While Tennessee law permits minors sixteen years and older to consent to mental health care without parental consent, I do not treat minors without parental permission/authorization.  Medical summaries and/or copies of session progress notes are available for a fee upon request. 

*Most insurance companies contract and reimburse for a maximum of 45-minute therapy sessions. 

 

Insurance Usage and Issues of Confidentiality and Privileged Communications:

Many patients elect to file third party insurance coverage, including Medicare, for services rendered.  I will file insurance for you, provided you authorize me to do so and provide me with the necessary information for filing such claims.  As you know, the world of health care has experienced a tremendous change in the manner in which insurance companies reimburse for third party payment.  Many plans require an initial precertification of care before you can use your insurance benefits.  It is your responsibility to make sure such precertification requirements are met by you if you elect to use your insurance benefits (i.e.,referral from your primary care medical doctor, employee assistance program,and other "gatekeeping" mechanisms such as calling an 800 number for approval). 

 

If information in reference to primary and/or secondary insurance is inaccurate, you, the financially responsible person are required to pay the full treatment fee amount and address your concerns to your insurance company.  You are responsible for all but primary insurance fees at the time of your visit. If your secondary insurance pays, I will reimburse you at the time. 

 

I agree to bill primary insurance and bill secondary insurance but if either has changed, lapsed or denied your coverage, you are responsible for the treatment bill in full. Your signature indicates you understand and accept these terms: 

 

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Name                                                                                                 Date