HIPAA Notice of Privacy Practices | Plainfield, IL

HIPPA Notice of Privacy Services

Patient Registration Form

None of our providers are Medicaid-Approved/In-Network providers.

If you have Medicaid (in any form), we will provide services to you as a self-pay patient. Please be aware, under this situation, you must agree not to submit any claims to Medicaid for services provided to you by our practice and understand our practice will also not submit any claims to Medicaid for services provided to you by our practice.

Please do not submit this form, as we do not want you to delay getting the services you need, and we will not schedule an appointment for you under this situation.

If you have any paperwork/forms (for example- Disability (Long- or Short-Term), Employment-related, FMLA, School-related, SSI, SSDI, etc.) that urgently need to be completed, our providers will not complete any paperwork/forms until they have a solid understanding of your clinical case and needs. This almost always takes several sessions but is not something that will be completed at your first appointment, or even early in your care with us.

Please do not submit this form, as we do not want you to delay getting the services you need, and we will not schedule an appointment for you under this situation.

If you are seeking services related to a Worker’s Compensation case, we unfortunately do not provide services for Worker’s Compensation cases.

Please do not submit this form, as we do not want you to delay getting the services you need, and we will not schedule an appointment for you under this situation.

If you are court-mandated to complete an evaluation or participate in treatment, we unfortunately do not provide court-mandated services.

Please do not submit this form, as we do not want you to delay getting the services you need, and we will not schedule an appointment for you under this situation

Patient Information

Name

Middle Name

Last Name

First Name/Nick Name

Patient’s Date of Birth

Date patient’s on

Patient’s Sex

Female
Male

Patient’s Preferred Pronouns

Patient’s Steet Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s Telephone Number

Can we leave voicemail messages at this phone number?

Patient’s 2nd Telephone Number (Work, Parents, Spouse, etc.)

Can we leave voicemail messages at this phone number?

Financially Responsible Person Information

Who will be financially responsible for this patient’s balances (Patients Under 18 Years Old Must Have Someone Else as Their Financially Responsible Person)?

Name (copy)

Name (copy) (copy)

Name (copy) (copy) (copy)

Financially Responsible Person’s Date of Birth

Financially Responsible Person’s Sex

Female
Male

Financially Responsible Person’s Preferred Pronouns

Financially Responsible Person’s Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Financially Responsible Person’s Telephone Number

Can we leave voicemail messages at this phone number?

Email (copy)

Is there a custody arrangement in place for this patient (Please be aware, we only allow one person to be designated as the Financially Responsible Person on the account)?

Employee Assistance Program (EAP) Information

Are you planning to use EAP services (You must have an authorization number to use EAP services)? *Note- EAP sessions can only be used for psychotherapy (they cannot be used for Psychiatric Medication Management, or Psychological Assessment/Testing)*

EAP Company Name

EAP Authorization Number

EAP Telephone Number

Primary Insurance Company Information

Primary Insurance Company Name

Primary Insurance Policy Holder’s First Name (Exactly as Listed on Your Insurance Card)

Primary Insurance Policy Holder’s Middle Name (Exactly as Listed on Your Insurance Card) (Optional)

Primary Insurance Policy Holder’s Last Name (Exactly as Listed on Your Insurance Card)

Primary Insurance Policy Holder’s Date of Birth

Single Line Text

Single Line Text (copy)

Primary Insurance Policy Phone Number (Usually on the Back of Your Insurance Card Listed as Customer Service or Something Similar)

Secondary Insurance Company Information

Secondary Insurance Company Name

Secondary Insurance Policy Holder’s First Name (Exactly as Listed on Your Insurance Card)

Secondary Insurance Policy Holder’s Middle Name (Exactly as Listed on Your Insurance Card) (Optional)

Secondary Insurance Policy Holder’s Last Name (Exactly as Listed on Your Insurance Card)

Secondary Insurance Policy Holder’s Date of Birth

Secondary Insurance Policy Identification Number/Member ID

Secondary Insurance Policy Group Number

Secondary Insurance Policy Phone Number (Usually on the Back of Your Insurance Card Listed as Customer Service or Something Similar)

Services-Related Information

Have you previously even received services from our practice?

Are any of your family members current or prior patients of our practice?

What is the name of your family member(s) who are currently or have previously been patients of our practice?

What Type(s) of Services are You Seeking (Select all that apply)

Psychiatric Medication ManagementManage your struggles through medication
Psychotherapy- Manage your struggles through talking to someone and learning ways to manage and cope with them
Psychological Testing/Assessment- Evaluate the causes or origins of your struggles, or Seeking help to determine the causes or origins of the issues

Preferred Sex of Provider

Female
Male
Does not Matter

Preferred Provider for Psychiatric Medication Management (If you know)-

Preferred Provider for Psychotherapy (If you know)-

How did you learn about our practice?

Single Line Text

What is your relationship to the Patient?

How would you prefer us to contact you?

Email
Telephone

What is your email address?

What is your telephone number?

If you prefer a telephone call, what are the best times of day to call (Select all that apply)?