Still Waters After Dark - After Hours Telepsychiatry in Pennsylvania

Insurance Notice

Still Waters After Dark is currently accepting commercial insurance and self-pay only. Medicare and Medicaid plans are not currently accepted for this service. This may change in the future based on coverage, network participation, and service availability. If you select Self-Pay / No Insurance, you understand that Still Waters will treat this visit as self-pay and payment will be due according to the posted self-pay rate. If you have active health insurance but choose to self-pay, you are responsible for understanding your plan’s rules regarding self-pay services and reimbursement. By selecting self-pay, you certify that the insurance information you provide is accurate and complete.

First Name

Last Name

Date of Birth

Current Age

Street Address

City

State

Zip Code

Physical location at time of appointment (if different from home address):

You must be physically located in Pennsylvania at the time of every telehealth appointment. If you are outside Pennsylvania, the visit cannot proceed.

Phone Number:

Alternative Phone Number (if applicable)

Email address

Primary Insurance

No Insurance / Self-Pay

Highmark / Blue Cross Blue Shield

UPMC Health Plan

Geisinger Health Plan

Aetna

UnitedHealthcare / Optum / United Behavioral Health

Tricare

Other Commercial Insurance

Insurance:

Do you have secondary insurance?

Yes No

Please list secondary insurance, ID #, Group #

Front of Insurance Card

Add file

Please upload a file

Back of Insurance Card

Add file

Please upload a file

Reason for Request, Chief Concerns:

Current Psychiatric Medications:

Any suicide attempt in the past?

Yes No

Any self-injury in the past 12 months?

Yes No

Any psychiatric hospitalization, partial hospitalization, or ER visit for mental health in the past 12 months?

Yes No

How many Psychiatric Hospitalizations? If none, answer "N/A". If you have had hospitalization(s), please list approximate date/year, duration, and details.

In the past 30 days, have you had thoughts of ending your life?

Yes No

Do you currently have suicidal thoughts with a specific plan or intent to act?

Yes

If YES -- Please call 911 or 988 immediately.

In the past 30 days, have you had thoughts of seriously harming or killing another person?

Yes No

Are you currently hearing or seeing things that others do not, or strongly believing things others say are not real?

Yes No

In the past 30 days, have you had a period of several days with unusually high or irritable mood, much less need for sleep, and markedly increased energy or risky behavior?

Yes No

Are you currently using alcohol, benzodiazepines, opioids, or other substances in a way that may require detoxification or withdrawal management?

Yes No

Additional comments regarding any “Yes” answers:

A “Yes” response does not automatically exclude you. It may require clinical review before scheduling.

Are you currently prescribed any controlled substances?

Yes No

Please list any current controlled substances that are prescribed:

Policies/Notices

By submitting this request, I understand that Still Waters After Dark is intended for routine outpatient telepsychiatry services and is not a crisis, detoxification, or emergency service.

Submission of this form does not guarantee acceptance as a new patient and does not establish a patient-provider relationship.

I understand that controlled substances are not prescribed to patients receiving care exclusively through telehealth through Still Waters After Dark.

I confirm that I have read and understand the Insurance Notice.

I understand that the Surescripts medication history database may be reviewed for medication reconciliation and safe prescribing.

I understand that I must be physically located in the state of Pennsylvania during all telepsychiatry sessions.

What Happens Next

After submission:

Still Waters staff will review your request and verify insurance information when applicable.
If accepted, you will receive an invitation by text and/or email to establish your Still Waters patient portal.
You consent to receiving routine appointment, portal, and administrative communications by text message and email.
Additional self-report questionnaires and intake forms may be required and must be completed within 24 hours of receipt.
A $75 deposit is required to reserve your initial Still Waters After Dark appointment due to the limited availability of evening and weekend appointments. Your appointment is not secured until the deposit is received. The deposit will be applied toward your patient responsibility or self-pay balance for the appointment. If you cancel or reschedule at least 24 hours before your appointment, the deposit may be refunded or transferred to a new appointment. If you cancel or reschedule with less than 24 hours’ notice, or fail to attend the appointment, the deposit will be forfeited. If Still Waters cancels the appointment, the deposit will be refunded in full or transferred to a rescheduled appointment.
After-hours appointment availability is limited. Missed appointments and late cancellations are subject to the Still Waters After Dark cancellation/no-show policy.
Failure to complete required forms, provide payment information, or complete the requested deposit may result in release of the appointment time.

I have read and understand the above policies and notices.

Yes No Other

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