Healthcare BHCG Form

Healthcare BHCG Form

Patient Information

Provide complete legal name and contact information. This information will be used for scheduling, billing, and clinical record identification.

Insurance Information

Provide the insurance information for billing. If patient is uninsured, indicate "Self-Pay".

Medical & Behavioral Health History

Provide relevant medical and behavioral health information. Accurate information assists in safe and effective treatment.

Consent for Treatment

I hereby consent to assessment and behavioral health treatment provided by Behavioral Health Care Group (BHCG) clinicians. I understand that treatment may include psychotherapy, counseling, medication management (if applicable), and coordination with other health providers. I understand risks may include temporary increase in emotional distress, recall of unpleasant memories, changes in relationships, and that no results can be guaranteed. I understand I may withdraw this consent at any time by providing written notice, except to the extent that BHCG has already acted in reliance on this consent.

I consent to receive behavioral health treatment from BHCG providers.

I consent to the provision of services through telehealth/remote technologies when offered. I understand benefits and limitations of telehealth and may decline telehealth services.

Authorization to Use and Disclose Protected Health Information (PHI)

I authorize BHCG to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. I authorize BHCG to release information to insurers, third-party payors, and to any persons designated below when necessary for my care or payment of services. I understand that certain disclosures are permitted or required by law and that there are special limits on disclosure of psychotherapy notes, substance use treatment records, and other sensitive records except as authorized below or as required by law.

I authorize direct payment of insurance benefits to BHCG and permit BHCG to furnish necessary information to secure payment. I understand I remain financially responsible for charges not paid by my insurer.

Financial Responsibility & Billing

I agree to be responsible for payment of services rendered, including co-payments, deductibles, and charges for services not covered by insurance. I understand the agency may seek payment from me if insurance does not reimburse. Missed or late-cancelled appointments may incur fees as specified by BHCG policies.

Acknowledgements and Notices

I acknowledge that I have been offered or received a copy of the BHCG Notice of Privacy Practices describing how my health information may be used and disclosed and my rights with respect to that information.

I acknowledge receipt of the Notice of Privacy Practices.

I authorize BHCG to leave appointment reminders or clinical messages on voicemail or answering services at the phone numbers provided.

I consent to receive appointment reminders and limited health information via SMS/text messages at the number I have provided (carrier rates may apply).

Certification

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize BHCG clinicians to provide treatment consistent with this consent. I understand I may revoke authorizations in writing, except to the extent BHCG has already acted in reliance on the authorization. I understand the exceptions to confidentiality include imminent risk of harm to self or others, suspected abuse or neglect of vulnerable persons, and disclosures required by law or court order.

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