New Client Form

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Client Information

Emergency Contact Information

Insurance Information

(N/A if Not Applicable)
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      HIPAA Disclosures

      (Please list all family members or close friends you authorize)

      Notice of Privacy Practices

      *Please click the above link to read the full Notice of Privacy Practices*

      Medical History

      Thank you for choosing Rainier Behavioral Health for your mental health needs. We are committed to building a successful clinician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc).

      INSURANCE CLAIMS
      Insurance is a contract between you and your insurance company. We are NOT a party of this contract. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
      PARTICIPATING INSURANCES
      If your insurance plan is one with which we are not a participating provider, you will be responsible for payment in full. However, as a courtesy, we will file your initial insurance claim and if not paid within 30 days you will be responsible.

      COPAY'S / DEDUCTIBLE
      All co-payments, deductibles and past due balances are due at time of check-in unless previous arrangements have been made with management or a billing coordinator. We accept cash, check, credit cards and HSA/HFA cards.
      RETURNED CHECKS
      The charge for a returned check is $40 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.
      REFERRALS AND PRE-AUTHORIZATIONS
      Certain health insurances (HMO,POS, etc.) require that you obtain a referral or prior authorization from you Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or pre-authorization, you are responsible for obtaining it. Failure to obtain the referral and/or pre-authorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility. Alternative payment arrangements or rescheduling of your appointment may be necessary if not obtained.

      PRIVATE PAY
      Private pay clients are required to make a full payment on the day of service. When paid in full at time of service, a 5% courtesy discount will apply.
      CANCELLATION OF APPOINTMENTS
      If it is necessary to cancel a scheduled appointment, we require at least 24 hours advance notice.
      LATE CANCELLATIONS
      A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24-hour advance notice.
      NO-SHOWS:
      A no-show is when a patient misses an appointment with no notice or shows up too late to the appointment to be seen.
      A $75.00 fee will be billed to your account for late cancellations and for no-shows.
      Repeatedly missing visits jeopardizes your care.
      Your insurance company will not be billed as insurance companies do not reimburse for late cancels and no shows.
      It is up to the discretion of each clinician to allow continuation of care after repeated missed appointments.

      MINORS
      The parent(s) or guardian(s) is responsible for full payment and will receive the billing statements.
      OUTSTANDING BALANCE POLICY
      If payment is not made on the account, a single phone call will be made to try to make payment arrangements. If no resolution can be made, the account will be sent to the collection agency and possible discharge from the practice.
      In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collections costs including attorney fees and court costs.
      Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party.
      *Extended payment arrangements are available if needed. Please ask to speak with a manager or the billing coordinator to discuss a mutually agreeable payment plan. It is never our intention to cause hardship to our patients, only to provide them with the best care possible and the least amount of stress.

      * I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

      INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

      You and your therapist have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, your therapist may require that you meet via telehealth. If you have concerns about meeting through telehealth, you and your therapist will talk about it first and try to address any issues. You understand that, if your therapist believes it is necessary, your therapist may determine that you return to telehealth for everyone’s well-being.
      *Please note, availability of telehealth services vary by clinician*
      If you decide at any time that you would feel safer staying with, or returning to, telehealth services, your
      therapist will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue you and your therapist may also need to discuss. Telehealth services are often reimbursed at the same level as face-to-face meetings in the office. You understand that by coming into the office, you are assuming the risk of exposure to the Coronavirus (or other public health risk). This risk may increase if you travel by public transportation, taxi, or ridesharing service.
      To obtain services in person, you agree to take certain precautions which will help keep everyone (you, your therapist, our families, other staff, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in you and your therapist starting/returning to a telehealth arrangement. Initial each statement to indicate that you understand and agree to these actions:

      You will only keep your in-person appointment if, to the best of your knowledge, you are symptom free.

      • You will allow staff to check your temperature with a no contact thermometer upon entry.
      • You will wait outside the clinic until no earlier than 5 minutes before your appointment time.
      • You will wash your hands or use alcohol-based hand sanitizer after you enter the building.
      • You will adhere to the safe distancing precautions we have set up in the waiting room and therapy rooms. For example, you won’t move chairs or sit where we have signs asking you not to sit.
      • You will wear a mask. If you do not have a mask, we will provide you with a mask.
      • You will keep a distance of 6 feet from your therapist, staff and others in the clinic. There will be no physical contact (e.g. no shaking hands) with your therapist or staff.
      • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
      • If you are bringing your child, you will make sure that your child follows these sanitation and distancing protocols.
      • You will take steps between appointments to minimize your exposure to COVID.
      • If you have a job that exposes you to other people who are infected, you will immediately let your therapist and our staff know.
      • If your commute or responsibilities or activities put you in close contact with others beyond your family, you will let your therapist and our staff know.
      • If a resident of your home tests positive for the Coronavirus, you will immediately let your therapist and our staff know. We will then begin or resume treatment via telehealth.

      Rainier Behavioral Health may change the above precautions if additional local, state or federal orders or health guidelines are published. If that happens, your therapist will talk with you about any necessary changes.
      Rainier Behavioral Health has taken steps to reduce the risk of spreading the Coronavirus within the office and we have posted our ongoing efforts on our website and in the office. Please let your therapist know if you have questions about these efforts.
      Your therapist and you understand that we are committed to keeping you, our staff, and all of our families safe from the spread of the virus. If you show up for an appointment, and your therapist, or our office staff believe that you have a fever or other symptoms, or we believe you have been exposed, your therapist will require you to leave the office immediately. Your therapist and you can follow up with services by telehealth as appropriate.

      Your Confidentiality in the Case of Infection

      If you have tested positive for the Coronavirus, your therapist may be required to notify local health authorities that you have been in the office. If your therapist has to report this, your therapist will only provide the minimum information necessary for the health authority’s data collection and will not go into any details about the reason(s) for your visits.
      By signing this form, you are agreeing that your therapist may contact local health authorities without an additional signed release.
      This agreement supplements the general informed consent/business agreement that you and your therapist agreed to at the start of your work together.

      Consent for Telehealth services

      As a client of Rainier Behavioral Health, I understand it is possible that at some point in my treatment, services may be provided via Telehealth, as described below. I understand and agree to the following with respect to use of Rainier Behavioral Health’s Telehealth services:
      *Please note, not all clinicians offer telehealth options, this does not guarantee that a telehealth session will occur*
      1. I understand that Telehealth is health/mental health services provided by Rainier Behavioral Health via interactive audio and video technology while the provider is at a different location than me. Telehealth may be provided by Rainier Behavioral Health’s physicians, psychiatrists, psychologists, social workers, or other licensed professionals.
      2. I understand that these Telehealth services may involve the communication of my health information, orally and visually. Specifically, I understand that Telehealth services include, but are not limited to, consultation, treatment, and transfer of health data using interactive audio and video. The laws that protect the confidentiality of my health information apply to these services the same as in-person services. As such, I understand that the information disclosed by me during any Telehealth session is confidential. However, there are both mandatory and permissive exceptions to confidentiality.
      3. I understand that there are risks and consequences of using these services including, but not limited to, the possibility that, despite Rainier Behavioral Health’s reasonable efforts, the transmission of my health information could be disrupted or distorted by technical failures. I agree that Telehealth is appropriate for my circumstances despite these risks. I understand that when I receive Telehealth services from a location other than at Rainier Behavioral Health, my own device and internet connectivity may impact the quality of the services and that Rainier Behavioral Health does not have control over my end of the transmission.
      4. I understand that Telehealth services may not be the same as in-person services, where non-verbal communication (body signals) are readily available to both provider and client.
      I have read and understand the information provided above.
      I hereby consent to participate in Telehealth services under the terms described above.

      Your information will be encrypted.

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