New Patient Intake Packet

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Payment of services is handled prior to your session

A copy of your insurance card(s) and drivers license is required

Emergency Contact Information

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Patient Information (complete this section only if you are the patient)

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If Yes, Name

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Patient Information
If Patient Is A Dependent

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If Yes, Name

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Primary Insurance Information

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Secondary Insurance Information

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Please read each item carefully and initial where indicated

Item 1– Consent For Treatment (All Patients Must Sign Consent For Treatment)

I hereby give consent for myself or the named minor patient to be treated by Sarah Evans, M.Ed., NCC, LPC, CART CCTP. If the above named patient is a minor who is or has been involved in any court proceedings, I have/will provide proof, by the attached court documents, that I have the legal right to request treatment for the above named minor. (If conjoint or marital therapy, both parties must sign consent for treatment.)

Item 2 – Assignment Of Insurance Benefits/Release Of Information

I hereby authorize my insurance carrier to pay benefits directly to Sarah Evans, M.Ed., NCC, LPC, CART CCTP / SOS LifeRing, PLLC for services provided to myself or my insured dependent, realizing I am responsible to pay for all services provided. I hereby authorize the release of pertinent information required by my insurance carrier to process insurance claims for payment to Sarah Evans, M.Ed., NCC, LPC, CART CCTP/SOS Life Ring.

Item 3 – Missed Appointment / Late Canceled Appointments

Unless canceled at least 24 hours in advance, my policy is to charge you for missed and late cancelled appointmentsat my full rate (Individual Therapy = $150.00; Family Therapy = $170.00). I may or may not call to confirm and remindpatient of their appointments. Please help me serve you better by keeping scheduled appointments.

Item 4 – Financial Policy

I acknowledge that I have read understand and accept the financial policies mentioned above for this office.

Items 1-4, initialed by myself, indicate my understanding of legal authorization for said terms and conditions in connection with the treatment of the above named patient.

Providers Billing Service

Consent for the release of confidential information (Must be signed in order for us to bill your insurance)

Sarah L. Evans / SOS Life Ring
(Disclosure made by)

(Your Insurance Company/Managed Care Company Name)


The disclosure shall be limited to the following specific types of information: Insurance Benefits/Verifications, Claim/Payment Status, Treatment Plans, Authorizations, E- Mailing/Faxing/Online/Electronic Billing

For the purpose of: INSURANCE REIMBURSEMENT / THERAPEUTIC TREATMENT, I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) and that in the event this consent expires automatically as described below.

Specification of the date, event, or condition upon which this consent expires:

(ONE YEAR AFTER ALL PAYMENTS RECEIVED)

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    By Submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit" you agree to hold SOS Life Ring harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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