Varad NeuroPsych Registration Form | Varad Integrative Psychiatry Clinic for Mental Health And Holistic Wellness Center Bellevue

NeuroPsych Program Patient Registration

Patient Information


Marital Status

Single Married Widowed Divorced Separated Partnered

Gender

Male Female

Employment Status

Full Time Part Time

Emergency Information


Please list two people we can contact in case of emergency. At least one must be someone you do not live with


Person one

Person two

Provider


Please list your primary provider information

Insurance


Primary Insurance

Policy Holder

Self Spouse Parent Other

Policy Holder’s Occupation

Full Time Part Time

Secondary Insurance

Policy Holder

Self Spouse Parent Other

Policy Holder’s Occupation

Full Time Part Time

PATIENT CONSENT


Consent for Medical Treatment:


  • I consent to diagnostic evaluations and treatments as deemed necessary and appropriate by clinical providers of NeuroPsych Program. I understand the purpose of this/these visit(s).
  • I understand that NeuroPsych Program offers educational experience to residents, medical students, professional healthcare entities students, and others with specific health-related learning needs. I authorize these residents/students to observe my care and, if appropriate, participate in that care. I understand that these residents and students are not employees or agents of NeuroPsych Program. The acts or omissions of such residents and students are the responsibility of their sponsoring institutions, not of NeuroPsych Program.
  • NeuroPsych Program assumes no liability for the loss of money or damage to articles of value.

  • Consent for Billing and Medical Information Release for Billing:


    As a courtesy to you, we will bill all primary and secondary insurance claims. Let us know if you do not want us to file your insurance claims for you. YOUR INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY.


    Medicare Patients with a Secondary Insurance:


  • I certify that the information given by me in applying for payment under Title XVIII of the Social Security Acts is correct. I request that payment of authorized benefits be made.
  • I assign the benefits payable for physician’s services to the NeuroPsych Program.
  • I authorize any holder of medical and/or other information about me to be release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.
  • I understand that NeuroPsych Program cannot assure me of Medicare payment for any service, nor are they responsible if Medicare disallows a lab or x-ray charge incurred from a visit to NeuroPsych Program. I understand that I will be billed from NeuroPsych Program if
  • 1) The charges incurred have been applied to my Medicare deductible

    2) If I do not have a second insurance, and/or

    3) If Medicare and my second insurance do not cover the total charges incurred at my visits to the Clinic.


    All Patients:


    I authorized NeuroPsych Program to release to my insurance provider(s) any medical information relating services rendered for insurance processing, quality assurance, or utilization review. The information to be released for insurance processing will be diagnosis and/or documentation of service provided for which charges are to be made. The information to be released may include psychiatric, developmental disability, alcohol and/or drug abuse information, HIV testing, and AIDS or AIDS related disease diagnosis unless specified by the following:


    I understand that this authorization for releasing information will be effective for one year from the date of my signature unless otherwise stated below or revoked through written notice to the Medical Records Department of NeuroPsych Program. Alternative date if not one year: _________.


    Assignment of Benefits:


    I hereby authorize payment directly to Reliance Madical Clinics, PLLC of the medical expense benefits otherwise payable to me by the Insurance Provider. I understand that I am financially responsible to the Clinic for charges not covered by Insurance.


    Receipt of Privacy Notice:


    I acknowledge receipt of NeuroPsych Program’s Notice of Privacy Practices.


    By signing below, I hereby consent to the above agreement.


    Patient Signature

    PRIVACY & PATIENT RIGHTS


    This notice summarizes how the NeuroPsych Program may use or disclose your medical information and your rights provided under the new Health Insurance Portability and Accountability Act (HIPAA).


    You have the right to:


    • Obtain a copy of the Notice of Privacy Practices upon request. This document explains your privacy rights and how your information may be used by NeuroPsych Program.
    • Request a restriction on certain uses and disclosures of your information. We are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
    • Inspect and request a copy of your health record. We may deny your request under very limited circumstances. If you are denied access to health care information, you may request that the denial be reviewed by another health care professional chosen by someone on our health care team. We will abide by the outcome of that review. There is a fee for this service.
    • Request an amendment to your health record. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if the information was not created by our health care team, is not part of the information kept by our facility, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete. Please note that even if we accept your request, we are not required to delete any information from your health care record.
    • Obtain an accounting of disclosures of your health information. The accounting will only provide information about disclosures made for purposes other than treatment, payment or health care.
    • Request communication of your health information by alternative means or locations. Your request must be in writing, and NeuroPsych Program may deny your request if it is not practical.
    • Provide the clinic with a signed authorization. This document will be used to disclose your health care information for other reasons besides treatment and payment.
    • Revoke your authorization. You may request in writing to revoke your authorization to use or disclose health care information except to the extent that action has already been taken.
    • Direct any complaint of our health care information practices to us or to the Department of Health and Human Services of the United States. You can file a complaint to our director of the clinic or you can file a complaint to the Dept. of Health and Human Services by addressing your written complaint to: Secretary, Dept. of Health and Human Services.

    NeuroPsych Program Obligations to you are:


    • To provide written notice of how the NeuroPsych Program uses and discloses your health care information. This notice of Privacy Practices will explain your privacy rights.
    • That your health care information will not be used for marketing activities.
    • That only the minimum necessary information will be used and disclosed except for treatment activities.
    • To protect your health care information with Business Associates. The NeuroPsych Program will have written agreements with vendors and suppliers who require your health information.
    • To use and disclose your protected health care information for treatment, payment, hospital, and to satisfy state, federal, law enforcement and oversight reporting requirements.

    I acknowledge receipt of NeuroPsych Program Privacy & Patient Rights.


    By signing below, I hereby consent to the above agreement.


    Patient Signature

    AUTHORIZATION FOR EMAIL COMMUNICATION


    This authorization for email communication will allow us to email you information regarding a number of exciting new services on the horizon at NeuroPsych Program. We would like to be able to inform you of these services/events as they become available. We appreciate that you have chosen NeuroPsych Program as your provider for Health Care services and would like to continue to provide with the best services possible.


    NOTE: Due to health care privacy laws, this email communication will not be used to send information regarding appointments, diagnoses, prescription requests and/or any other health care related information. You will still need to call NeuroPsych Program for those services.


    By signing below, I authorize NeuroPsych Program to communicate with me via email for the purpose of sending information about new services/events. I acknowledge that this communication does not include appointments, diagnoses, prescription requests or any other delivery of care. In order to communicate about these issues I must contact NeuroPsych Program office.


    Your signature below indicates your agreement to the above policy and all of the conditions herein.


    Patient Signature

    AUTHORIZATION FOR CO-PARTICIPATION OF CARE


    I authorize NeuroPsych Program to share information regarding my health care with the following persons (leave blank if there are no persons you wish to participate in your care). *The Clinic cannot share any information to anyone whose name is not stated below.



    Information authorized to be shared (check all that apply):

    All healthcare information

    Only the following healthcare information:

    Laboratory Results Radiology and Imaging Reports (X-ray, MRI, CT Scan, etc.) Appointment Information
    Account Information (Billing) Insurance/Reimbursement

    Your signature below indicates your agreement to the above policy and all of the conditions herein.


    Patient Signature

    AUTHORIZATION FOR TELEPHONE MESSAGING


    NeuroPsych Program provides reminder calls, follow-up calls and due to the nature of these calls we may need to leave a message with an individual and/or answer machine.


    Your signature below indicates your agreement to the above policy and all of the conditions here in.


    Patient Signature

    FINANCIAL POLICY


    To prevent any misunderstanding about our fees and your medical insurance, please be aware that:


    • 1. You are liable, NOT YOUR INSURANCE COMPANY, for the bill and any uncovered portion of our fees. You may receive a separate bill from the lab that analyzes services rendered such as pap smears, cultures, and any biopsies performed (this list is not all-inclusive).
    • 2. Any balance on your account is your responsibility. Your monthly statement reflects your previous balance, new charges, payments or credits. Accounts overdue by more than 90 days are sent to collections.
    • 3. Check with your insurance company regarding preferred provider status before your appointment to avoid increased out of pocket expense.
    • 4. Co-pay amounts are due at the time of service.
    • 5. $30 fee will be issued on all returned checks.
    • 6. If you are unable to make your appointment, please contact the office 24 hours prior to scheduled appointment, otherwise, there will be a $40 fee for missed appointments.
    • 7. There is no charge for medical records requested by the patient to another provider. Requests of records for any other purpose will be $22 for up to 1-20 pages, $0.50per Page after that. Current rate of chages applicable as per DSHS and state of Washington.
    • 8. Letters requested by patients will require a $25 preparation and processing fee.
    • 9. Other charges may apply.

    NO SHOW/CANCELLATION POLICY


    • Failing to show for an appointment without calling to cancel 3 times in a row or 3 cancelations within a 2-month period will result in your case being closed.
    • All clients who see one of our medication providers are required to keep all their appointments with their therapist. Even if the client is attending their medication appointment, if they are not compliant with the therapist appointments the case will be closed.
    • If your case is closed due to no shows or cancellations, you can request another intake to be re-assessed for services after 90 days and go through the intake process again. You may or not be approved and will not necessarily get the same provider or therapist.

    Your signature below indicates your agreement to the above policy and all of the conditions herein.


    Patient Signature


    MEDICATION POLICIES


    • No prescriptions will be refilled on Fridays, Saturdays, Sundays or Holidays.
    • Require 6 days minimum to process prescription(s) renewal and/or pick-up requests.
    • The patient is responsible for knowing when medication(s) will need to be refilled (no early refills).
    • Prescription phone-in/pick-up: Monday-Thursday during business hours ONLY (9:00 am to 4:00 pm).
    • Prescriptions will not be filled for unauthorized “walk-in” patients. Must phone the appropriate NeuroPsych Program.
    • Non-controlled/non-narcotic prescriptions require a follow up appointment every 3-6 months.
    • Controlled-substances prescriptions require a follow up appointment every 30-90 days.
    • New symptoms and/or events require a clinic appointment. Provider unable to diagnose via phone.
    • Signed “Controlled-Substance/Narcotic Policy” required if using narcotic/controlled medications.
    • No early refills if medications are overused/abused/misused. Must follow prescription directions.
    • No medication/prescription will be replaced if lost, stolen, misplaced, overused, etc (treat like money!!).
    • Medications are for the prescribed individual’s use only. It is illegal to “share” your medicine.
    • Patient must pick-up his/her prescription(s) in person, unless pre-authorized by staff.

    I understand and accept the protocol listed above. Failure to comply may subject immediate termination of prescriptive medications.


    Your signature below indicates your agreement to the above policy and all of the conditions herein.


    Patient Signature