New Patient Paperwork

This paperwork is to be completed prior to your first appointment with a Clinician.

Please remember to click the “SUBMIT QUERY” button when prompted.

This will ensure that we will receive all of the forms.

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Insurance Authorization and Financial Agreement- SECTION 1

I hereby authorize the provider of services to furnish information to insurance carriers concerning my condition and treatment. I hereby assign to the provider all payments for medical services rendered to my dependents or myself. As a courtesy, Atlantic Counseling & Consultation will check your benefits with the insurance company however; it is recommended that you contact your insurance company as well to confirm your behavioral health coverage. I understand that it is my responsibility to know my insurance benefits and that I am responsible for copays, coinsurance and/ or deductibles that are required by my insurance plan. I understand that it is my responsibility to obtain prior authorizations, if applicable, from my insurance company for services at Atlantic Counseling & Consultation, Inc. I understand that it is my responsibility to provide Atlantic Counseling & Consultation, Inc. with accurate and up to date information about my insurance coverage at the time of the visit. I understand that failure to do so may result in non- payment from my insurance company. I understand and agree that I am responsible for full payment of any services not covered by insurance.

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Cancellation Policy

24-hour notice is necessary to cancel any appointment or you will incur a charge of $90.00 for the late cancel or missed appointment (please refer to page 2 of the Patient Agreement)
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PATIENT AGREEMENT- SECTION 2

Introduction

Welcome to Atlantic Counseling and Consultation, Inc. Our practice is designed to provide you with the highest quality care at a reasonable fee. We are individually licensed, by the state, as independent practitioners. Each therapist has several years of experience providing individual, group, family or couples therapy as well consultation to schools and agencies.

Fees, Payment, Insurance and Consultation

For Psychotherapy, our initial evaluation fee is $250.00. Thereafter, our fees are $190.00-$210.00 based on the length of the session. For a Medication consultation, the amount can vary from $200-$350, depending on the length and complexity of the appointment. ACC clinicians are contracted providers for most major health plans. When we have a contract with an insurance carrier, we will bill that carrier directly. You are responsible for the co-payment, co-insurance, and /or deductible. Payment is due at the time of the visit. In the event that we do not receive payment from your insurance, you will be responsible for the bill. Your plan reserves the right to limit the number of visits. If you continue past that point, it is understood that you will be responsible for the bill. If we are asked to attend meetings, appear at court, consult with schools, or complete requested paperwork that is deemed clinically appropriate, the fee will be our hourly rate plus preparation and travel.

Medical

We suggest that you get a full physical before beginning treatment, to rule out any medical problems.

Confidentiality

Our counseling practice is a professional one. We are bound by our own personal and professional ethics to hold everything you say in strict confidence. There are four (4) exceptions to this rule: 1.) If I have your permission to consult with other professionals, such as doctors, teachers or previous therapists. 2.) If I am subpoenaed to court to testify about you. 3.) If, in my clinical opinion, you are in danger of hurting yourself or others. 4.) If you allege sexual or physical abuse. All licensed clinicians are mandated by the state to report abuse. Please review our Notice of Privacy Practices for Protected Health Information. These exceptions, especially the second and third, are extreme situations that happen infrequently. We do feel, however, from the onset it is important for you to know our legal and moral obligations, as well as our conviction, that we will respect and uphold your privacy.

Time

We expect to begin and end on time for each session. Should you be delayed, we will still have to end on time. Should we be delayed, you will be provided the full session.

Cancellation & No Show Policy

Please schedule your sessions at a time that you will be available. In order for treatment to be of most help to you, it is essential that you prioritize your commitment to attend all scheduled sessions. If there is a need to cancel and we are notified at least 24 hours in advance, there will be no charge for the appointment. There is a fee of $90.00 for any appointments you fail to keep if we have not been notified at least 24 hours in advance. Insurance will not pay for appointments cancelled late or missed appointments; you will be billed directly. We highly encourage you to plan accordingly to avoid any charges.

Our Agreement

My job is to help you achieve your goals within the parameters of this contract. By signing our names below, we have agreed to comply with all the points. We agree to work together until our goals are reached or until we decide, together, to discontinue.

Name*
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NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION-SECTION 3

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This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Atlantic Counseling & Consultation, Inc., is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called “HIPAA) and it’s Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. This health information is referred to as “Protected Health Information” or “PHI” for short. We are also required under Section 164.520 to give our patients this notice (in paper or electronically as the patient wishes) of our legal duties and privacy practices concerning their Protected Health Information, and also to tell our patients about their rights under HIPAA and the Regulations. Uses and Disclosures Treatment: Providing, coordinating or managing health care and related services, consultation between health care providers relating to a patient or referral of a patient for health care from one provider to another. Payment: Billing and collecting for services provided, determining plan eligibility and coverage, recertification and medical necessity review. Health Care Operations: General agency administrative and business functions, quality assurance/improvement activities; medical review; auditing functions; licensing, survey, certification and credentialing actives. We are permitted to use or disclose information about you without consent or authorization in the following circumstances: 1.) Certain law enforcement purposes such as helping to identify or locate a suspect, fugitive, material witness or missing person, or to comply with a court order or subpoena and other law enforcement purposes; 2.) To coroners, medical examiners and funeral directors, in certain circumstances, for example, to identify a deceased person, determine the cause of death or to assist in carrying out their duties. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Individual Rights

You have certain rights under the federal privacy standards. These include: • the right to request restrictions on the use and disclosure of your protected health information • the right to receive confidential communications concerning your medical condition and treatment • the right to inspect and copy your protected health information which is maintained in a designated record set, EXCEPT FOR PSYCHOTHERAPY NOTES, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or protected health information that is subject to the Clinical Laboratory Improvements Amendments of 1988 [42 USC 263a and 45 CFR 493 (2)]. • The right to amend or submit corrections to your protected health information • The right to receive an accounting of how and to whom your protected health information has been disclosed • The right to receive a printed copy of this notice

Atlantic Counseling and Consultation, Inc. Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting: The Clinical Director Atlantic Counseling and Consultation, Inc. 49 Pleasant Street South Weymouth, MA 02190

Atlantic Counseling and Consultation, Inc. is providing all patients with a notice that describes how medical information about you may be used and disclosed and how you can get access to this information. This notice meets the requirements as stipulated in the Health Insurance Portability and Accountability Act (45CFR 165.520). Please sign below acknowledging receipt of the Notice of Privacy Practices for Protected Health Information.

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Payment Policy and Automated Billing Authorization- SECTION 4

We have recently updated our policy and now require all patients to keep an active credit card on file. The credit card will be billed for each appointment to cover your copay, coinsurance and/ or deductible based on your insurance benefits. The credit card will also be billed for any services that are not covered by your insurance company and any missed appointments. If your account should accrue a balance and it is not cleared on or by the 10th of the month, then your card will be billed. The No show/ late cancellation fee ($90) will be billed to your credit card the next business day and a receipt will be emailed to you upon request. For copay, coinsurance, deductible and self- pay payments, a receipt will be emailed upon request.

Name*
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Authorization

By signing below, I agree to adhere to the updated policy and I authorize Atlantic Counseling & Consultation to charge my credit card the deductible/copay/coinsurance amount(s) that are determined by my insurance carrier, self- pay amount(s), No show/late cancellation fees and/or sessions already rendered but not covered by insurance. By signing below, I understand that I will call the office with my credit card number and that number will be kept on file until I notify the office.

I have read the statement and authorize my credit card to be used.*
Are you the cardholder?*
Billing address*
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**Please note: The "dd" does need to be completed for the form to be sent. Typically, that information is not available so please add 01 to that field. Thank you.
If you would prefer to provide your credit card information to us over the phone, please call the office at (781) 335-6000 extension 305. The Administrator is available Monday -Thursday from 8:30am-4pm or you can provide the information to your Clinician at your appointment.
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