Is the patient under the age of 18?

FRONT of card

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BACK of card

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For Patient or Parent/Guardian as patient is a minor

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Patient first name

Patient last name

Address

City

State

Zip  

Social Security #

Birthdate

Parent's Email Address

Parent's Work Phone Number

INSURED PARTY'S EMPLOYER

Employer phone

Address

City

State

Zip code

Employment Status

Name

Relationship

Date of birth

Social Security Number

Email

Address

City

State

Zip code

Name of Referring Party

REFERRAL INFORMATION: MAY WE RELEASE THIS INFORMATION TO YOUR REFERRAL SOURCE?

Are you/your child/adolescent taking any medications or supplements at this time?

By signing below, I affirm that I have read and understand BMC Troy's HIPAA Privacy Notice:
 

Date:

One of the goals of our office is to help keep your health care costs as low as possible. One way we attempt to do this is to keep our costs to a minimum. Please help us in the following ways:

1. ALWAYS bring your current health insurance card and identification to the office. We will need to scan both of them at your first visit. Please notify us at time of check-in of any changes in insurance, address, marital status, custody, phone number, etc. In cases of divorce or separation, the parent authorizing treatment and attending sessions on behalf of/with their child/adolescent will be the parent responsible for the full balance associated with the visit, to be paid in full on each day of service.
2. It is the responsibility of the cardholder/patient to know the details of eligibility and coverage with the insurance carrier. If your insurance requires a referral to see a specialist, it is your responsibility to notify us prior to the appointment date. If you have multiple insurance plans, it is your responsibility to see that they coordinate correctly.
3. If you do not have any insurance coverage, please come prepared to pay your visit in full on each day of service.
4. We are required by our insurance contracts to collect all co-payments at the time of service. You MUST pay your co-pay/deductible at the time of the visit. If you do not, we will consider charging a $10 fee that will not be billable to your insurance carrier.
5. We will attempt to help you understand your mental health coverage; however, office visits or telemedicine visits may not be covered by your insurance plan. If your claim is denied for a non-covered service, you are financially responsible for the cost of the visit.
6. Some mental health policies may not cover the entire year of services. If your mental health coverage is exhausted for any given year, you are then responsible for payment at the standard BMC-Troy cash rate for services rendered, which are different and generally higher than the rates utilized within your insurance.
7. If your account has a credit, these are reviewed and processed on a quarterly basis.
8. Please be aware that if you choose to schedule an appointment with a doctor/nurse practitioner and a therapist in the same day, your insurance may not cover both sessions, leaving you responsible for whatever is not paid by them. As such, we will not schedule same day appointments with two providers.
9. You will be charged a $90 missed appointment or late cancellation fee for any appointment that is not cancelled 24 hours (or more) before the day/time of the appointment.  However, if the appointment is scheduled on a Monday it must be cancelled by the Friday before by noon to avoid a charge. Late cancellations due to inclement weather are not an exception to this rule; however, the charge may be waived at the provider’s discretion. Frequent cancellations may result in termination of treatment as we are unable to provide safe, comprehensive treatment with inconsistent appointment attendance. This charge is not billable to your insurance. Our office utilizes an automatic appointment reminder system, but this reminder is a courtesy. You are responsible for your appointment regardless of whether you received this text/email. If you do not show for one of our group sessions, you will be charged $30 for each missed group session.
10. If you arrive late for your appointment, your provider may not be able to see you and the appointment will then need to be rescheduled. A late cancellation fee of $90.00 may be charged at the discretion of the provider.
11. If you are having a Qb Test, you are responsible for the copay/deductible at the time of the test. We will attempt to bill your insurance for the remainder, but if it is not a covered benefit in your policy, you are responsible for the full amount.
12. If you are having Genotyping testing, there is a $25 service charge due at the time of swabbing. The remainder of the charges are rendered and collected by Genesight. Our service charge is not billable to your insurance.
13. For an initial appointment with a prescriber, you/your child will be given rating scales to complete prior to your next visit.  We have a $12.00 rating scale fee that is not billable to your insurance.  If the prescribers feels the scales are necessary to repeat at any later point to assess treatment response, the same $12.00 fee will be applied.
14. If you require services that are not a covered benefit (ex. marital therapy), you will need to sign the “Non-Covered Service” form and pay in full on the day of the visit.
15. If you write a check and it is returned to us with “insufficient funds,” you will be charged $35 per insufficient funds check. In addition, prior to the next appointment, you will be responsible to re-pay the money owed to BMC - Troy along with the $35 charge, using cash or a credit card only.
16. If your account becomes past due, we will take whatever steps are necessary to collect the debt.
17. Prescription refills require a minimum of 48 hours' notice. Federally controlled prescriptions must be escribed utilizing additionally encrypted software. In order to escribe controlled substance medications, you will be charged a yearly fee of $20 to cover administrative costs. This charge will be re-applied each year in January and is in effect until the end of December of that calendar year. We do not pro-rate.
18. If you are requesting copies of medical records for yourself or to be sent to another office you will be required to complete a release of information prior to us completing the request. If a letter/report or other type of form is requested to be completed, the amount of the charge for this type of request is at the discretion of the prescriber or therapist, and must be paid prior to receipt of the document.
19. Please be advised that the Behavioral Medical Center will not tolerate verbal or physical hostility/aggression towards its staff members. This type of behavior will be grounds for immediate termination of care.
20. Audio and/or Visual recording of a session of any type is strictly prohibited and will result in immediate termination of care at our office.
21. I have read this General Office/Financial Policy and understand that I am ultimately responsible for any charges incurred. This is an agreement between Behavioral Medical Center – Troy and I, the patient or patient representative. By executing this agreement, I agree to pay for all services rendered or charges incurred, as indicated above.

Due to the fact that insurance benefits are varied and constantly changing, we have the following office policy regarding payment:

I hereby authorize payment directly to Behavioral Medical Center - Troy for any medical services performed from the insurance company information that I provide. I shall be legally responsible for any out of pocket costs, such as co-pays, deductibles, and services that are not a covered benefit under the policy. I understand that Behavioral Medical Center - Troy will bill as a courtesy, and if my insurance company does not pay within 45 days, that I may be billed.

I authorize Behavioral Medical Center - Troy to release any medical information requested by my health insurance company to process a claim.

When possible, our staff will assist you in determining what your benefits are, but because we don’t always receive clear information from insurance companies, sometimes errors are made. We ask you to verify benefit information with your insurance company. If problems arise with respect to reimbursement, we will attempt to help you resolve them. But the ultimate responsibility for the full fee for services rendered is yours.

Please Note: If you must cancel an appointment, we ask that you give us at least a 24-hour notice; otherwise, you will be charged $90.00 for the late cancellation or “no show.” Neither charge can be billed to your insurance company.

If you have any questions regarding the preceding policy, please ask one of our office staff and we will be happy to assist you.

In signing below, I am acknowledging that I understand the above policies and comply with them by accepting full responsibility for payment of services.

Telepsychiatry Consent

Telepsychiatry is a form of telemedicine that allows patients to access psychiatric care using an audio-video interface. BMC utilizes Doxy.me, which is a HIPAA-compliant telemedicine platform.

Benefits of Telemedicine:

Improved access to psychiatric care by enabling a patient to remain in his/her home or office.

More efficient psychiatric evaluation and management.

Maintaining treatment schedule despite logistical obstacles.

Possible Risks of Telemedicine:

As with any medical procedure, there are potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to:

-In rare cases, information transmitted may be poor resolution, which may make the video portion of the visit of lesser quality

-In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand the following:

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telepsychiatry, and that no information obtained in the use of telepsychiatry which identifies me will be disclosed to researchers or other entities without my consent.
• I understand that I have the right to withhold or withdraw my consent to the use of telepsychiatry in the course of my care at any time, without affecting my right to future care or treatment.
• I understand that a variety of alternative methods of psychiatric care may be available to me, and that I may choose one or more of these at any time.

Billing of Telehealth Services:

I understand that if possible, BMC will bill my telehealth visits to my insurance company. I understand that I am responsible for any applicable deductible, co-insurance or co-pays, or for the cost of the session if it is not covered by my insurance. I also understand that the BMC Payment Policy also applies to telehealth services.

Patient Consent To The Use of Telepsychiatry

I have read and understand the information provided above regarding telepsychiatry, have discussed any questions with BMC staff (if necessary), and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepsychiatry for my care at the Behavioral Medical Center – Troy.

Patient or Parent/Guardian Signature

INVOICE, SMS (TEXT) & EMAIL COMMUNICATION CONSENT

By signing below, I hereby authorize Behavioral Medical Center to send me SMS (text) messages to provide me updates regarding my care such as appointment Confirmations, etc. I understand that I can simply opt-out of this consent by letting Behavioral Medical Center know that I no longer wish to receive SMS (text) messages from them or by texting back the work STOP to any SMS (text) message I receive from them. I also understand that the frequency of the SMS (text) messages from Behavioral Medical Center will vary.

By signing below, I hereby authorize Behavioral Medical Center to send me emails to provide me with updates regarding my care such as Appointment confirmations, billing statements, electronic invoices, etc. I understand that I can simply opt-out of this consent by letting Behavioral Medical Center know that I no longer wish to receive emails from them. I also understand that the frequency of emails I receive from Behavioral Medical Center will vary. *If you consent please add to your emails whitelist to ensure our email messages reach your inbox.

Patient or Parent/Guardian Signature