New Patient Packet for Bayview
Pre-Intake
Patient Last Name
Patient First Name
Maiden Name (if applicable)
Date of Birth
Street Name
City
State
Zipcode
County
Telephone
Email address
Communication Preference:
Phone
Text
Mail
Email
Do Not Contact
Are you homeless?
Yes
No
Are you pregnant?
Yes
No
Marital Status:
Married
Divorced
Single/Never Married
Separated
Widowed
Common Law/Cohabitating
Are you a Veteran?
Yes
No
Hearing Status:
Hearing
Hard of Hearing
Deaf
Do you need an interpreter?
Yes
No
Primary Language
English
French
German
Russian
Spanish
Other
Race
Alaskan Native
American Indian
Asian
Black/African American
White/Caucasian
Native Hawaiian/Other Pacific Islander
More than one race reported
Other
Ethnic Origin
Cuban
Mexican/Mexican American
Not Hispanic
Hispanic
Puerto Rican
Other
Employment Status
Full time
Disabled
Unemployed
Not looking for work
Student
Retired
Homemaker
Part time
Inmate of institution
Supported Employment
Not Applicable
Do you have insurance?
Yes
No
Primary Insurance:
Self-Pay
Medicare
Medicaid
BCBS
UHC
Other
Effective Date:
Primary Insurance Policy Subscriber Name
Subscriber Date of Birth
Secondary Insurance:
Medicare
Medicaid
BCBS
UHC
Other
Effective Date:
Secondary Insurance Policy Subscriber Name
Subscriber Date of Birth
Next of Kin
Emergency Contact
Referral Source
Self
Physician
DHR
State/Federal
Probation/Parole
Other
Primary Source of Income
Wages/Salary
Public Assistance (food stamps/TAMF)
Retirement/Pension
Disability (SSI/SSDI)
None
Other
How many people in the household?
Total Annual Household Income ($):
Expected Payment Source
Worker's Compensation
Personal Resources (Self/Family)
Commercial Insurance (BCBS, UHC)
Medicare
Medicaid
Medicare/Medicaid
Other
STATEMENT OF UNDERSTANDING AND CONSENTS
Review each area:
Treatment:
I hereby authorize BayView Professional Associates to provide me with psychiatric and therapy treatment services, and if it is my child or ward, I hereby give consent for treatment.
Consent for Follow-up contact:
I consent to BayView Professional Associates staff members contacting
myself
other contact
by letter, questionnaire, or telephone for establishing my current condition. I understand this information will be held in confidence and will not be disclosed without my written consent. I further understand this consent for follow-up will remain valid for a period of
ONE
year following my discharge from the program. I understand that I may revoke this consent at any time in writing.
I do not want to be contacted.
Name:
Address:
Phone#:
Health Information Exchange (HIE):
AltaPointe participates in a HIE called Care Quality and other designated HIEs. I understand that any physician or hospital that participates in the HIE either directly or indirectly may request for the purpose of my continuity of care the following limited set of records regarding my care: Allergies, Demographics, Labs, Immunizations, Medications, and Problem Lists. You may chose to Opt-Out of allowing your health information to be shared through the HIE by requesting an Opt-out Form.
All other releases will follow the practices explained in your Notice of Privacy Practices.
Payment Agreement:
For and in consideration of services rendered by BayView Professional Associates, patient (responsible person) herby agrees to and guarantees payment of all BayView Professional Associates charges incurred for the account of the patient from the date of admission until discharge. I understand that if an agency or company is responsible for payment of services, that agency or company will have the right to review the services I receive at BayView Professional Associates.
I understand that I may be charged a fee or co-payment for services and that it is expected, if I am responsible for the payment of these services, to pay for them as they are received. I further understand I should contact BayView Professional Associates if there are any changes to my insurance.
Methods of Payment
– Our office accepts the following payment methods: Cash, Personal Check, Visa, MasterCard, Discover, and American Express. I understand that by providing my credit card, I am consenting to this agency to save my credit card information and use it for pending charges.
There will be a $25.00 charge for all returned checks.
No Show Fee
: I understand I will incur a
no-show fee
as scheduled below for any missed appointment if I do not cancel or reschedule with proper advanced notice. This does not apply to patients enrolled in our sliding scale fee program. Appointments can be canceled or rescheduled by calling (251) 450-2250 or accessing our patient portal.
Appointment Type
Advanced Notice
Psychological Testing
72 Hours
All other appointments
24 Hours
Appointment Type
Fee
Psychological testing
$300
Therapy appointment
$100
MD, PA, or NP
$200
Excessive no-show appointments and late cancellations may result in suspension of future scheduling or dismissal from the practice. I understand that I can dispute a no-show fee or make payment arrangements for outstanding no-show fees by contacting the Practice Manager at 251-450-2250.
Administrative Fee
: I understand that there is a
$25.00
administrative fee for any detailed letters, Family Medical Leave Act (FMLA) forms, disability forms, or any other detailed forms that are completed by BayView staff. Please allow 7-10 days for forms to be completed; I understand that my administrative forms will not be released until my $25.00 payment is received.
Fee Schedule:
I understand that I am responsible for payment for services rendered by BayView Professional Associates at its standard rates provided to me on the fee schedule.
Self-Pay –
I agree to pay BayView Professional Associates in full for services rendered. BayView reserves the right to discontinue treatment at any time if payment is not made in full on my outstanding balance. I understand that non-payment toward my self-pay balance may result in dismissal from the practice with a 30-day notice.
Medicare (if applicable):
Patient certified that the information given in applying for payment under Title XVIII (18) of the Social Security Act is correct. Patient authorizes any holder of medical or other information about Patient to release to the Social Security Administration or its intermediaries or insurance carries any information needed for this or a related Medical claim. Patient requests that payment of authorized benefits be made on his/her behalf.
Medicaid (if applicable):
Patient certified that the information given in applying for payment under Title XVIII (18) of the Social Security Act is correct. Patient authorizes any holder of medical or other information about Patient to release to the Social Security Administration or its intermediaries or insurance carries any information needed for this or a related Medical claim. Patient requests that payment of authorized benefits be made on his/her behalf.
Assignment of Insurance Benefits and Agreement to Pay Any Balance
: Patient (responsible party) irrevocably assigns and transfers to BayView Professional Associates all right, title and interest to medical reimbursement benefits under any and all applicable medical insurance policies covering patient, for the payment of treatment and medical care being provided. Patient (responsible party) authorizes payment directly to BayView Professional Associates of said medical reimbursement benefits. Patient (responsible party) is responsible for and co-payments, co-insurance, deductibles, and/or other amounts specified by my insurance. I understand that my agreement with my insurance carrier is a private one, and that BayView Professional Associates does not routinely research why my insurance carrier has not paid or why it paid less than anticipated for care. I understand that I am responsible to know my individual insurance coverage. Please remember your insurance policy is between you and your insurance company and not with the insurance company and your doctor.
Consent for Residents, Interns, and Medical and Nursing Students to Participate in my Treatment
: I am aware that, residents, interns, medical and nursing students, could be present for educational purposes. I understand that in the educational process they may observe or participate in my or my child’s treatment and/or review my or my child’s medical record.
Patient Rights Statement
: I understand that BayView Professional Associates subscribes to a Patient Rights Statement, which has been made available to me. I have had the opportunity to have the Patient Rights Statement explained to me.
Grievance Process
: I have been furnished with a copy of the Grievance process and have had the opportunity to have it explained to me.
Procedure to Review Records
: I have been furnished with a copy of the Procedure to Review my health record and have had the opportunity to have it explained to me.
Notice of Privacy Practices
: I have been furnished a copy of the Notice of Privacy Practices and have had it explained to me. I understand that the information concerning my treatment will be held in confidence by the BayView Professional Associates staff unless I give specific written consent for the release of information. In case of emergency BayView Professional Associates is authorized to request or release that information which is essential to handle the emergency.
Also, BayView Professional Associates staff will not release any information except as required by law or Court Order under compelling disclosure, or in a situation deemed potentially life-threatening, and in the following instances: Suspected Child Abuse, threats of physical harm to self and/or others, espionage, or sabotage.
The confidentiality of your participation may also be protected by federal and state laws and regulations. The violation of federal requirements is a crime, and suspected violations may be reported. Federal regulations do not protect from disclosure of information related to a consumer’s commission of a crime against BayView Professional Associates property or personnel, or reports under state law of suspected child abuse or neglect (See 42 U.S.C. 290 ee 3 for federal laws 42 CFR Part 2 for federal regulations).
Please refer to the Health Information Exchange section of this document for HIE information.
Rehabilitation Act:
It is the policy of BayView Professional Associates, in compliance with Section 504 of the Rehabilitation Act of l973, to afford qualified handicapped persons an opportunity to receive benefits or services that are equal to that offered non-handicapped persons. Any person who feels he/she has not received treatment in accordance with this policy may submit a compliant with the Patient Relations Department, AltaPointe Health, 5750-A Southland Drive., Mobile, Al. 36693.
Psychiatric Advance Directives:
I have a psychiatric advance directive and have provided a copy to BayView Professional Associates.
I do not have a psychiatric advance directive and have been provided information by BayView Professional Associates.
Integrated Healthcare Pharmacy Services
: As a patient at BayView Professional Associates my prescriptions may, but are not required, to be filled at the Integrated Healthcare Pharmacy located at Gordon Smith Drive. AltaPointe Health has an ownership interest in Integrated Healthcare Pharmacy and offers the on-site pharmacy services for the convenience of the patient. It is the patient’s decision as to where he/she chooses to fill their prescription.
Psychiatric Telehealth Services:
I have been furnished information regarding Psychiatric Telehealth. I understand that the information obtained while using Telehealth may be used for diagnosis, therapy, follow-up, referral, and/or consultation, and may include one or both of the following: Live two-way audio and video and output data from medical devices and sound and audio files. The interactive tele-video equipment and telecommunication lines used are HIPAA approved for consumer security and privacy. I understand the expected benefits and potential risks of participating in Telehealth. I also understand that my telehealth services will be provided by a Bayview Professional Associates Credentialed Staff.
Click the following link to review the referenced forms:
BayView Patient Policies
**By signing below, I agree and have reviewed the Statement of Understanding and consent forms required by BayView Professional Associates and/or Montlimar Outpatient Services.
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NB-61 updated electronically 1/24/2023; Revised again 7/31/2023