Campos Behavior Health Services LLC 4701 Spotsylvania ...



Client Demographic InformationClient Contact InformationFirst Name:_________________________ M.I.:______ Last Name:_______________________ Date of Birth:________Home Address:___________________________________City:_____________________ State:____ Zip Code:_______Cell Phone:( ) - Home Phone:( ) - Email:_________________________Social Security Number / required for insurance claim:_____________________________________________________Primary Insurance CarrierName of Insurer:____________________________________________________________________________________Insurance ID #: ____________________Group #:_________ Effective Date of Policy:________ Co-pay Amount:______Guarantor Information / if other than you:Guarantors First Name:_____________________ M.I.:_____ Last Name:___________________ Date of Birth:________ Relationship to you:__________________ Phone: ( ) -_______ Email:_______________________________Home Address:___________________________________ City:_____________________ State:____ Zip Code:_______Social Security Number / required for insurance claim:_____________________________________________________Secondary Insurance Carrier / if applicableName of Insurer:____________________________________________________________________________________Insurance ID #: ____________________Group #:_________ Effective Date of Policy:________ Co-pay Amount:______Guarantor Information / if other than you:Guarantors First Name:_____________________ M.I.:_____ Last Name:___________________ Date of Birth:________ Relationship to you:__________________ Phone: ( ) -_______ Email:_______________________________Home Address:___________________________________ City:_____________________ State:____ Zip Code:_______Social Security Number / required for insurance claim:_____________________________________________________Office PoliciesNo-Show, Late Cancellation and Late Policy:There is a significant wait time for psychiatric appointments. I understand that if I miss an appointment and do not notify the office at least 24 hours in advance I will be charged $50.00 for the missed session. My insurance company does not cover this fee. This must be paid at the time of the next scheduled appointment. I understand that if I am more than 10 minutes late for an appointment I may have to re-schedule it. If I am unable or willing to wait I may be charged $50 for the missed appointment. My insurance company will not cover this fee.Termination of Services Policy:You may terminate services at any time. Your provider may terminate services for any of the following reasons. Two consecutive no shows or cancellations giving less than 24 hours’ notice.Failure to follow the mutually agreed upon treatment plan. Failure to take medications as prescribed.Failure to follow up with securing a therapist if recommended as part of a treatment. Threatening, intimidating or verbally abusive language or behaviors.Failure to report medications prescribed to you by other providers.Any illegal activity, including but not limited to diverting controlled substances prescribed to you.Violating confidentiality standards. This includes the confidentiality of other patients and staff.Failure to pay your bill, inability or unwillingness to make payment on an outstanding bill prior to being seen for services. If your provider is no longer practicing and cannot continue to provide services due to illness or other family emergencies. If you are terminated or transferred out of the practice you will receive a letter by certified mail explaining termination of the provider/patient relationship. You will be given information about other psychiatrists/mental health providers in the area. You will have access to proper care and coordination and medication refills for 90 days after receiving a notice of termination. It is your responsibility to make sure we have a current address on file for us to contact you.By signing below, you indicate that you understand and agree to adhere to this office policy. Client / Legal Guardian Signature:________________________________ Date:_____________Relationship to Client / if other than you:_________________________________________Privacy Act Notice / Client Rights StatementYour protected health information may be used and disclosed by your physician, our office staff and others outside of our office who is involved in your care and treatment for providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice. Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. We may disclose your protected health information, as necessary, to a primary care physician that provides is to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by aiding with your health care diagnosis or treatment to your physician.You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact your provider if you have questions about access to your medical records.Statement of Financial ResponsibilityThe service you have elected to participate in implies a financial responsibility on your part. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. I have read the above policy regarding my financial responsibility to Campos Behavioral Health Services for providing psychiatric services to me or the above-named client. I certify that the information is, to the best of my knowledge, true and accurate. Fees: 40 Minute: Psychiatric Evaluation: $175.00 (or as contracted with insurance carrier)20 Minute: Medication Management: $120.00 (or as contracted with insurance carrier)Missed Appointment without 24-hour notice: $50.00 (not covered by insurance)Some health insurance carriers require the patient to pay co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patients to pay prior to services provided. Thank you for your cooperation in this matter. Non-Payment Policy:Campos Behavioral Health Services reserves the right to send any bill that is more than 90 days delinquent to a collection agency. In the absence of prompt payment, the undersigned understands that personal demographic and financial information concerning these professional services will be released to the collection agency for collection. The collection agency will act as the provider’s “Business Associate” in accordance with our privacy practices (notice of privacy practices is provided as part of these intake forms. The undersigned will be responsible for the full bill plus any charges made by the collection agency if necessary.Client / Legal Guardian Signature:________________________________ Date:_____________Relationship to Client / if other than you:____________________________________________Informed Consent for TreatmentHedy K. Campos is a Board Certified Psychiatric Nurse Practitioner currently licensed in the State of Virginia doing business as; Campos Behavioral Health Services and Virginia Psychiatric Associates 4701 Spotsylvania Parkway, Fredericksburg, VA 22407. Hedy K. Campos provides psychiatric evaluations and medication management for most psychiatric disorders. This process includes conducting a psychiatric diagnostic evaluation, and developing a comprehensive treatment plan. Treatment may include; making recommendations for psychotherapy, nutritional counseling, medications, and referrals to other healthcare providers. Your health records are confidential and privileged. However, there are instances in which confidential information can or must be released without your consent. These instances include, but are not limited to the following;Mandatory Reporting Requirements:Suspected child or elder abuse. If there is suspected or reported child or elder abuse, protective services are notified immediately. Serious threats of harm to others. When a threat to physically harm someone else is made by you, law enforcement is notified immediately. Serious threat to harm self. When a threat to injure or kill oneself is disclosed by you, law enforcement is notified immediately. If anyone else alleges that you threatened to physically harm them or yourself, law enforcement is notified immediately.Insurance reporting: When you are required to sign a release of information by your health insurance.Children: Clients under 18 do not have full confidentiality from their parents.Electronic communication: If you authorize electronic communication, including e-mail. All electronic communication risks a compromise of confidentlyCourt orders: Providers must release some clinical records if subpoenaed by a court of law. My signature indicates informed consent to participate in treatment services with Hedy K. Campos for myself or the client for whom I have the legal authorization to consent for treatment. I understand that psychiatry is not an exact science and no guarantees are made as to specific outcomes. I understand that Hedy K. Campos cannot guarantee that any specific medication will be prescribed and/or that any combination of medications and treatments will have the expected or desired affect. I understand I have the right to revoke this consent in writing and terminate services with Hedy K. Campos at any time. I have read and understand all the information on this sheet. By signing this consent, I voluntarily consent and request to participate in a Psychiatric diagnostic evaluation for the purposes of receiving ongoing medication management of my condition only and if needed, with Hedy K. Campos.Client / Legal Guardian Signature:________________________________ Date:_____________Relationship to Client / if other than you:____________________________________________Consent to Disclose Health Care Information With Family, Friend, Employer or Other[Optional Form]Client Name: ______________________________Date of Birth: ___Phone Number: ( ) - _ I hereby request and authorize that my health information be discussed and/or disclosed with the individual(s) I listed below. The individual(s) identified below are family members, friends, school officials, employers, or other persons involved in my care and/or the payment for my care. I agree that my treatment provider may share such information as my provider may determine relevant including; appointment times, required care, treatment goals, medications prescribed, referral services and current diagnosis. I understand that I have the right to revoke this request/consent by delivering written notice to my provider at any time. Please list the names of the individuals you authorize us to disclose health information related to your care and their relationship to you. Name: Relationship:______________________ ___________________________________________ ___________________________________________ ___________________________________________ _____________________I hereby release Campos Behavioral Health Services, and the provider I am requesting to release my health information, from all liability which may arise because of my authorized release of records. Should my case require review by a governing agency or another medical profession actively involved in my care to make a final determination, it is with my consent that a copy of these records will be submitted to the agency or medical profession for this review. Client / Legal Guardian Signature:________________________________ Date:_____________Relationship to Client / if other than you:____________________________________________Medical Release of Past Psychiatric Care RecordsClients Name:___________________________________ Date of Birth:___________________Address:______________________________________________________________________Phone Number:_________________________Treatment Dates from: _________ to_________I request and authorize: (enter your past psychiatric care providers contact information)Name: ________________________________________Fax #: ( ) - _Name: ________________________________________Fax #: ( ) - _Name: ________________________________________Fax #: ( ) - _To release copies of my clinical chart via fax or mailed to:Hedy K. Campos PMHNP-BC4701 Spotsylvania Parkway, Suite 101Fredericksburg, VA 22407Phone: 540-891-7891Fax: 540-891-2031camposbhs@I hereby release Campos Behavioral Health Services and provider I am requesting to release my health information from all liability which may arise because of my authorized release of records. Should my case require review by a governing agency or another medical profession actively involved in my care to make a final determination, it is with my consent that a copy of these records will be submitted to the agency or medical profession for this review. I understand that this authorization shall continue in effect following the date of my signature. I understand that this authorization may be revoked by me at any time by me providing written notice to Campos Behavioral Health Services to revoke this authorization. A photocopy of this authorization shall constitute a valid authorization. Client / Legal Guardian Signature:________________________________ Date:_____________Relationship to Client / If other than you:____________________________________________ ................
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