AUTHORIZATION & CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Treatment Authorization: *
I (print name)
consent to the use or disclosure of my protected health information by -View Psychiatric NP & Behavioral Therapy P.C. for the purpose of diagnosing or providing treatment to me or my minor child, obtaining payment for my health care bills or to conduct necessary health care operations at 1-View Psychiatric NP & Behavioral Therapy P.C.
Notice as to Nature of Services: I understand that the care I receive at 1-View Psychiatric NP & Behavioral Therapy P.C. may be nontraditional or unconventional. Many of these services may not be recognized as standard medical practices, and may be considered investigational or experimental. Medications prescribed may be approved by the FDA for a different condition than that for which it is prescribed for me. I understand my doctor may request laboratory evaluation that may include venipuncture, analysis of stool, urine, saliva and breath.
Notice that Services are not Primary Care: I understand that no physician or any other practitioner I see at 1-View Psychiatric NP & Behavioral Therapy P.C. is acting as my primary care physician unless otherwise agreed to by a physician in writing. As such, emergency services are not offered. I understand that even though my physician(s) and I-View Psychiatric NP & Behavioral Therapy P.C. practitioners may address issues affecting my general health, the practice is focused on psychiatric care and it is in my best interest to have a primary care physician to ensure that I am fully apprised of all available conventional means to address any medical conditions I may have. This is also important because services are exclusively office-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children. I also understand that it is my responsibility to inform 1-View Psychiatric NP & Behavioral Therapy P.C. who my primary care physician and specialists are, to let my physician know of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions, and that I should keep my physicians and any practitioners I see informed on an ongoing basis. I also understand that it is very important to let my primary care physician know about any treatments performed at 1-View Psychiatric NP & Behavioral Therapy P.C. in order to properly and safely coordinate my care. My primary care physician is: Name * Address: Phone City State Zip Code: I am also being treated for
Name * Address: Phone City State Zip Code: Continued Care: It is paramount you adhere to your treatment plan in its entirety. Unfortunately, failure to meaningfully participate in your mental health treatment may constitute grounds for the termination of care. Grounds for termination may include any combination of adverse medication, visit and/or financial compliance along with aggressive, abusive or drug seeking behavior. 1-View Psychiatric NP & Behavioral Therapy P.C. observes a strict three Strike policy. In the unlikely event the termination of care is mandated, you will be given appropriate referrals and thirty (30) days notice. Initials Name
Cancellation and/or No-Show Policy: 1-View Psychiatric NP & Behavioral Therapy P.C. urges you to keep every appointment, as treatment using psychiatric medications requires consistent monitoring. In the event you need to cancel an appointment, we require at least 24 hours notice, excluding Saturday and Sunday. Patients who cancel without proper notice or fail to show for a scheduled appointment will be subject to a $25.00 charge for each occurrence. Important Information Regarding Medication Refills: Refill requests must be received during business hours no less than one week prior to running out of medication. Refill requests are not addressed afterhours or on weekends. Medications cannot be refilled for those who have either missed or canceled their last appointment or have not been seen for two (2) months. Refills for controlled substances will not be issued outside of a regularly scheduled assessment. Initials Assignment of Benefits: I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to 1-View Psychiatric NP & Behavioral Therapy P.C. for all covered medical services and supplies provided to me during all courses of treatment and care provided by 1-View Psychiatric NP & Behavioral Therapy P.C. and/or its affiliated entities or otherwise at its direction Initials
I understand and agree this Assignment of Benefits will constitute a continuing authorization, maintained on file with I-View Psychiatric NP & Behavioral Therapy P.C, which will authorize and allow for direct payment to 1-View Psychiatric NP & Behavioral Therapy P.C. of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by 1-View Psychiatric NP & Behavioral Therapy P.C. If insurance payments are made directly to me, I will endorse such payments to 1-View Psychiatric NP & Behavioral Therapy P.C. within five (5) days of receipt of such payment.
Financial/Insurance Responsibility for 1-View Psychiatric NP & Behavioral Therapy P.C. Services: I understand and agree to the following policies regarding financial and insurance responsibilities. Payment is required at or before each visit. I am responsible for charges incurred for all treatment rendered. This responsibility includes co-pay, co-insurance, deductible amounts, non-covered and excluded items not paid for by my insurance carrier or other party responsible for coverage of my medical expenses. I agree that I am responsible for any payments for services my insurance carrier determines, either now or at a later date, to be unreasonable or not medically necessary. I further understand, 1-View Psychiatric NP & Behavioral Therapy P.C. will not be obligated to take action on my behalf against an insurance carrier for collecting or negotiating my insurance claim. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for 1-View Psychiatric NP & Behavioral Therapy P.C. to take action to secure payment of an outstanding balance owed. No Guarantees: I am aware that no practice of medicine is an exact science and acknowledge that there are and can be no guarantees as to accuracy or outcomes of any diagnosis or treatments that I receive at 1-View Psychiatric NP & Behavioral Therapy P.C.
Revocation of Authorization: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to 1-View Psychiatric NP & Behavioral Therapy P.C. Such revocation will not affect my financial responsibility to pay for services rendered by 1-View Psychiatric NP & Behavioral Therapy P.C. I understand that this revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Patient Acknowledgment: I certify that the information I provide to my practitioners and my insurance company is correct. I certify that I am here to receive medical care and for no other purpose. I do not represent any third party. By signing and dating this form, I acknowledge that I have received a copy of this Authorization and Consent. Patient Signature * Witness Signature * Comments
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