Healthcare Program Treatment Application

HEALTHCARE PROGRAM TREATMENT APPLICATION

Program Name:   Date Submitted:

Patient Information

Date of Birth:   Gender / Identity:

Phone:   Email:

Relationship:   Phone:

Insurance Information

Policy / ID Number:   Group Number:

Subscriber Date of Birth:   Insurance Phone:

Medical History

Primary Care Provider:   Current Treatment Provider:

Program Services & Treatment Goals

Individual Therapy    Group Therapy    Medication Management    Case Management

Desired Start Date:

Consent to Treatment and Acknowledgments

By signing this application, I consent to participate in the program named above and authorize the delivery of treatment and services as described and agreed between me and program clinicians. I understand that treatment may include assessment, psychotherapy, counseling, medication evaluation and management, and coordination with other health providers. I acknowledge that no specific outcome is guaranteed and that treatment carries potential benefits and risks, which may include temporary increases in emotional distress.

I understand that I retain the right to refuse or withdraw consent to treatment at any time, except where limited by law. I understand that clinicians will discuss alternatives, anticipated benefits, and significant risks of proposed interventions at the time treatment is initiated.

Exceptions to confidentiality include situations where disclosure is required by law: imminent risk of serious harm to self or others, suspected abuse or neglect of a minor or vulnerable adult, or as ordered by a court. Information necessary for administrative purposes, billing, coordination of care, and as authorized in the Release of Information section below may be shared consistent with applicable law.

Authorization for Release of Information

I authorize the program to obtain, use and disclose protected health information as necessary for treatment, payment, and healthcare operations, and for coordination with the following persons or organizations: family members, other health care providers, insurance carriers, and referral sources as indicated below. I understand that information released may include medical records, treatment plans, medication information, and progress notes as relevant to the purpose of the disclosure.

Purpose of Disclosure:   This authorization expires on:

I understand that I may revoke this authorization in writing at any time, except to the extent that the program has already acted in reliance upon it. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Financial Responsibility and Insurance Assignment

I authorize the program to submit claims to my insurance carrier and to receive payment directly from the insurance carrier for services rendered. I agree to be responsible for any co-payments, co-insurance, deductibles, or charges not covered by insurance. I understand that I remain responsible for payment of services if insurance denies coverage or if benefits are exhausted.

Billing Contact:

HIPAA Acknowledgment

I acknowledge that I have received or been offered a written Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights related to that information. I understand that I may request restrictions on certain uses and disclosures and inquire about the program's privacy practices.

I authorize the program to leave appointment reminders and other administrative messages at the contact numbers and addresses I have provided. I consent to receiving communication by phone, voicemail, email, or text message unless I indicate otherwise.

Preferred Contact Restrictions:

Certification and Applicant Attestation

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that knowingly providing false information may affect my eligibility for services. By signing below I consent to the treatment described herein and authorize use of my insurance and release of information as stated above. I understand that I may receive a copy of this application upon request.

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