New Patient Forms | Behavioral Health Providers

Step 1 of 8 — General Intake Form

Personal Information

Please provide your basic personal details. All fields marked with * are required.

First Name Please enter your first name.

Last Name Please enter your last name.

Date of Birth Please enter your date of birth.

Gender Please select your gender.

Marital Status

Social Security # (last 4 digits only)

Employer / School

Contact Information

Street Address Please enter your street address.

City Required.

State Required.

ZIP Required.

Phone Number Please enter your phone number.

Email Address Please enter a valid email address.

Contact Method Preferences

We will make every effort to preserve your privacy. Please indicate which contact methods are acceptable.

Email Contact

Cell Phone Contact

Home Phone Contact

Work Phone Contact

Emergency Contact

Emergency Contact Name Required.

Relationship Required.

Emergency Contact Phone Required.

Referral

How did you hear about us?

Referring Doctor (if applicable)

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Step 2 of 8 — Insurance & Guarantor Form

Insurance & Guarantor Information

Please provide your insurance details. If you are self-pay, skip the insurance fields and indicate below.

Payment Method *

Using Insurance Self-Pay TRICARE (Military)

Insurance Company * Required if using insurance.

Insurance Plan Name

Member / Insurance ID * Required.

Group Number

Insurance Phone

Mental Health Insurance Carrier (if different from primary)

Primary Subscriber (if different from patient)

Subscriber Name

Subscriber Date of Birth

Subscriber SSN (last 4)

Relationship to Patient

Guarantor (financially responsible party)

Guarantor is the same as the patient

Guarantor Full Name

Guarantor Relationship to Patient

Guarantor Phone

Guarantor Date of Birth

Guarantor Address (if different from patient)

Patient Acknowledgement

I understand that I am responsible for payment for services rendered to me by Behavioral Health Providers, P.C. regardless of whether I am reimbursed by my insurance company, and that any inaccuracy in information on this form may result in nonpayment by my insurance company. I have obtained preauthorization from my insurance company if it is a requirement to receive benefits. If there are any changes in my insurance coverage I will notify BHP immediately.

Step 4 of 8 — Physician Notification & Consent Form

Physician Notification & Authorization

Pursuant to Illinois Law PL 86-1434, we are required to notify your primary care provider of your treatment with us unless you state otherwise in writing. Please select one option below.

Primary Care Provider Status *

I have a primary care provider and authorize BHP to notify them of my treatment. I do not have a primary care provider. I DO NOT authorize BHP to notify my primary care provider of my treatment.

Please select one option.

Authorization to Release Information to Primary Care Provider

I understand that my records are protected under Federal and State confidentiality laws and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it.

Information to be released includes: diagnosis, treatment procedures, and details of my condition which help to coordinate treatment. I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will.

This authorization is valid for 90 days after last contact and may be cancelled in writing at any time.

Primary Doctor's Full Name

Practice / Office Name

Primary Doctor's Phone

Primary Doctor's Fax

Primary Doctor's Address

Patient Signature *

Draw your signature using your mouse or finger. This constitutes your electronic signature.

Step 5 of 8 — Financial & Treatment Policy Form

Financial & Treatment Policy Agreement

Please read the following policy carefully. Your signature below confirms your understanding and agreement.

Fees

Copays, coinsurance, or any amount not covered by insurance for any reason is due within 30 days of the bill date. We accept online payments through the patient portal, checks, MasterCard, or Visa. There will be a $25 fee for returned checks. Past due accounts may be subject to additional charges including collection agency fees, attorney fees, and court costs. To ensure you are notified of any balance, please notify us any time your email or mailing address changes.

Appointments

We realize that on occasion you will not be able to make a scheduled appointment. If this is the case, you may leave a cancellation message on our voicemail or email us at bhproviders@gmail.com. Please remember that this time has been reserved for you alone, so if you need to reschedule or cancel, let us know as soon as possible. If you are going to be more than 10 minutes late for your appointment it may need to be rescheduled.

Collection Policy

The balance on all accounts is due in full within 30 days of the billing date. We will make multiple attempts to contact you before any further action is taken. Any balance past due more than 90 days is subject to being sent to collections unless arrangements have been made. We are more than willing to work with you, so we ask that you let us know if there are any issues.

Telephone Consultations

Time spent with you on the telephone by your mental health professional — other than for appointment scheduling — may be charged at a prorated hourly rate.

Confidentiality & Release of Records

All information regarding patients is considered strictly confidential and will not be given out to anyone without your written consent. In the event of a request for transfer of records, records will be forwarded upon completion of a consent form.

Preparation of Forms & Reports

Forms and reports require chart review and often discussion with the client. Please allow 7 to 10 business days for completion and return of any forms or reports.

Insurance Billing

We will file your claim as a courtesy with your Primary Insurance Carrier. It remains your responsibility to pay any deductibles, copayments, or other amounts your carrier determines as payable by you. If your insurance carrier has not paid for our services after a 60-day period, you will be expected to pay your balance in full. It is your responsibility to provide us with updated information if your insurance company changes or your coverage terminates. By signing below, you authorize Behavioral Health Providers, P.C. to provide your health insurance company with all information necessary to process an insurance claim.

Your Role in Providing Accurate Information

It is your responsibility to pre-certify your initial visit and to know your plan's limitations, deductibles, and exclusions. If the insurance information you provide is later determined to be inaccurate, resulting in denial of your claim, you will be responsible for the amount denied by your carrier.

*Items marked with an asterisk are not reimbursable by insurance.

Preauthorization Notice: Your health insurance company may require you to obtain preauthorization before any payment will be made for our services. We advise that you contact your insurance company about your care schedule as soon as possible. If preauthorization is needed, notify us and work with your insurance company until prior authorization is approved.

Payment Authorization

You may add, remove, or change your payment method on file at any time securely through the patient portal. By checking the option below, you authorize Behavioral Health Providers to automatically charge your card on file for applicable amounts.

Client's Rights & Consent for Services

I authorize Behavioral Health Providers, P.C. to release any medical information to my insurance company which may be deemed necessary to process an insurance claim. I certify that the information provided on this form is correct to the best of my knowledge. I authorize my insurance company to assign benefits to Behavioral Health Providers.

I have read and understand the above policies. I understand that the information I have provided is to be used for management purposes and the agency will ensure confidentiality. My rights are protected under State and Federal confidentiality laws, and any release of information requires my consent except where required or permitted by law — including child abuse and/or neglect and the intent to harm others or myself.

I give my consent to the undersigned clinician to provide evaluation, treatment, and/or other services that we mutually determine to be appropriate. I am participating voluntarily and understand my right to refuse or discontinue treatment at any time.

Client / Guardian Signature *

Draw your signature above using your mouse or finger.

Print Full Name * Please print your name.

Date

Step 6 of 8 — Informed Consent for Televisits

Informed Consent for Televisits

This consent applies to all patients who participate in or may participate in video-conferenced / telehealth visits. Please read the full consent and sign below.

Agreement to Participate

I, the undersigned, agree to participate in video-conferenced visits (Televisits) with Behavioral Health Providers, PC. This means that I authorize information related to my health care to be securely electronically transmitted in the form of images and data through an interactive video connection.

Location

I understand that I must conduct such visits from a private setting where I will not be interrupted.

Equipment

I understand I must be connected to a secure network or connection. I agree to use only my own equipment for Televisits and will not use my employer's computer or network for the visit.

Identification

I understand that I may be asked to supply information to verify my identity prior to the visit proceeding. If other parties are present during the Televisit, they will also be identified and their purpose for attending will be clarified.

Nature of Televisit

My psychologist/therapist has explained how the Televisit is performed and how it will be used for my treatment, including how it may differ from in-person services.

Possible Risks

Risks that have been recognized include, but may not be limited to:

The technology may fail before or during the Televisit.
In rare cases, information transmitted may not be sufficient (e.g., poor resolution or audio) to allow for appropriate clinical decision making.
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment.
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

Expected Benefits

Potential benefits of a Televisit include, but are not limited to: improved access to care, more efficient evaluation and management, reduced travel time and cost, and easier availability.

Discontinuation

I understand that a Televisit can be discontinued at any time, either by me or by my psychologist/therapist. Any refusal to participate will not affect my continued treatment. I acknowledge, however, that diagnosis depends on information — if I withhold information, I assume the risk that a diagnosis might not be made or might be made incorrectly.

Alternatives

The alternatives to Televisits have been explained to me, including their risks and benefits. I understand that I can still pursue in-person visits, and that a Televisit does not necessarily eliminate my need to see my psychologist/therapist in person.

Follow-Up Care

If a Televisit is unable to provide all necessary clinical information, I will be informed of the need for an in-person evaluation. If I have an adverse reaction or if technological failure prevents communication, I will be informed of how to receive follow-up care.

Records

I understand that my Televisit may be recorded and stored electronically as part of my clinical record. Televisits, test results, and disclosures will be held in confidence subject to state and/or federal law. Copies of records are available to me upon written request.

Emergency Situations

I acknowledge that if I am facing or think I may be facing an emergency situation, I am NOT to seek a Televisit. Instead, I will seek care immediately through my own physician, the nearest hospital emergency department, or by calling 911.

Release from Liability

I unconditionally release and discharge Behavioral Health Providers, PC, and their affiliates, agents, employees, and designees from any liability in connection with my participation in remote Televisits.

Ethics & Professional Standards

Behavioral Health Providers, PC and its affiliates are licensed clinicians regulated by the State Board of Examiners. If I have any concerns about my care, my psychologist/therapist or their supervisor would be happy to discuss them with me.

Patient Signature *

Draw your signature above using your mouse or finger. Guardian signature is required if patient is a minor.

Print Full Name * Please print your name.

Date

Step 7 of 8 — Consent for Release of Information

Release of Information

Use this optional form to authorize Behavioral Health Providers to release your health records to another person, doctor, practice, or organization. If you do not wish to release information to anyone at this time, simply leave the toggle below unchecked and continue.

I would like to authorize a release of information to a third party.

I authorize Behavioral Health Providers, P.C. to release the selected information to the person, doctor, practice, or company listed below. This request will expire in 1 year unless a different expiration date is specified below. I understand that I may revoke this consent at any time in writing.

What to Release

Select the information to release: *

Any and all records — including but not limited to treatment notes, test results, insurance information, payment history, and balances. ONLY treatment notes and test results. ONLY insurance information, payment history, and balances.

Release To

Name of Person, Doctor, Practice, or Company *

Address

Phone Number

Expiration Date (default: 1 year from today)

Patient Signature *

Draw your signature above using your mouse or finger.

Printed Name

Date

Step 8 of 8

Review & Submit

Please review your information below before submitting. Click any section heading to go back and make changes.

New Patient Intake Forms

Authorization to Release Information to Primary Care Provider

Fees

Appointments

Collection Policy

Telephone Consultations

Confidentiality & Release of Records

Preparation of Forms & Reports

Insurance Billing

Your Role in Providing Accurate Information

Agreement to Participate

Location

Equipment

Identification

Nature of Televisit

Possible Risks

Expected Benefits

Discontinuation

Alternatives

Follow-Up Care

Records

Emergency Situations

Release from Liability

Ethics & Professional Standards

Forms Submitted!

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