Stress Management Center

Stress Management Center at Fernview

1115 Dunlap Road Anderson, SC 29621 / P.O. Box 1424 Anderson 29625 Phone 864-225-0792 Fax 864-226-396

PATIENT INFORMATION

First name

Middle Initial

Last Name

Date of Birth

SS#

Marital Status

Married

Single

Widowed

Divorce

Gender Identity

Cell Phone

Alternate Number

Occupation

Employers Name

Street Address

City

State

Zip

Email Address

May We Email You?

Yes

EMERGENCY CONTACT

Emergency Contact Name

Phone

Relationship to Patient

May we leave a detailed message

Yes

MEDICAL / MENTAL HEALTH / MEDICATION INFORMATION

May we contact your Primary Care Physician(s)?

Yes

Primary Care Physician(s):

Phone:

Current Medications:

Name of Medication:

Prescriber:

Condition Treated:

Dosage/Frequency:

FINANCIALLY RESPONSIBLE PARTY

(If different from patient)

Name

Phone

Relationship to Patient

Date of Birth

Address

State

Zip

INSURANCE / PAYMENT INFORMATION

Policy Holder’s Name

Primary Insurance Company

Policy Number

Policy Holder’s Date of Birth

Relationship to Client

Group Number

Insurance Filing and Payment Policy:

We are a provider for most major insurance companies. Please provide your correct and current insurance information. Client/guardians of minors are required to pay their co-insurance or co-payments at or before the time of service. It is the responsibility of the client/guardian to pay for any non-covered services, which may include, but are not limited to, phone consultations, record requests, professional letters, crisis support, and late/missed appointment fees.

Payment Policy:

Payment for your portion of insurance, cash pay, or other services is due on or before the day of service, unless other payment arrangements have been made with our office.

Collection Policy:

Unpaid balances that have been outstanding for 90 days or more may be referred to an outside collection agency

Acknowledgement and Agreement

I have read, understand, and agree to the above payment and insurance policies

Signature of Client /Representative

Date:

Notice of Privacy Practices (HIPAA)

Your Health Information is confidential and protected by law. By signing below, you acknowledge receipt of our Notice of Privacy Practices, available upon request.

Signature of Client /Representative

Date:

Authorization for Release of Information

I give / do not give (circle one) my permission to the Stress Management Center to share my psychological/psychiatric diagnoses or release information/records to the following agency/ person(s):

Name

Phone

Purpose Relationship

Name

Phone

Purpose Relationship

Name

Phone

Purpose Relationship

Name

Phone

Purpose Relationship

Medical Records Release Acknowledgment

I understand my medical records may contain sensitive information, including psychological/psychiatric or substance abuse details. I understand that I must sign a specific authorization to release any information except to my insurance provider.

Signature of Client /Representative

Signature of Parent or Legal Guardian (if applicable)

Date:

Consent for Treatment and Release

I have read and understand these forms. All of my questions have been answered. I give my consent to treatment and to speak with a clinician. I authorize my provider to discuss my care with other interoffice clinical providers as needed.

Signature of Client /Representative

Signature of Parent or Legal Guardian (if applicable)

Date:

For Couples/Family Counseling

All participants must sign and date the document below to acknowledge their understanding of session confidentiality. For minors (under 18) in joint custody, both parents must sign.

Name

Signature

Date:

Name

Signature

Date:

Name

Signature

Date:

Name

Signature

Date:

Card Authorization

To honor our agreement for services provided (in person or virtual), the Stress Management Center requires a payment method (HSA, credit, or debit card) on file in our confidential, encrypted system to cover co-pays or session fees unless other arrangements are made with office staff prior to your session. We are partnered with First Citizens Bank and pay additional fees for your convenience. You may cancel this authorization at any time by contacting our office. This authorization will remain in effect until canceled. For any payments made to your account(s), there will be a 3.5% charge per transaction (some HSA cards are exempt). We work with every client to help them receive the support services they need to embrace a healthy lifestyle. If you prefer, you may provide this information in person at our office.

Credit Card Information

Cardholders Name (as shown on card)

Expiration Date (MM/YY)

Card Number

Security Code

Zip code associated with billing address

Authorization

authorize Stress Management Center at Fernview to charge my credit card listed above for copays and/or balances

I understand my information will be securely stored in our encrypted EHR system for future transactions on my account. Payment is due the day of treatment, and a 2.5% fee may be added to any unpaid balances. While we will bill your insurance as a courtesy, you are responsible for providing current insurance information and for any balances not covered by your insurer. All copays and deductibles must be paid at the time of service. Some services may not be covered by insurance, and you are responsible for payment in those cases. If you are unable to pay your balance in full, please contact our billing office to discuss a payment plan. Accounts unpaid after 90 days may be sent to collections, and you are responsible for associated fees. The Stress Management Center may update this policy at any time. By receiving services, you agree to these terms.

Date

Signature