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

EMERGENCY CONTACT

MEDICAL/ MENTAL HEALTH/ MEDICATION INFORMATION

Health & Family Medical / Mental Health History:

FINANCIALLY RESPONSIBLE PARTY

(If different from patient)

INSURANCE / PAYMENT INFORMATION

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.

Please initial each statement below

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.

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)

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

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.

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

Card Authorization

enter 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

Authorization

I, __________________________________, 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.

Stress Management Center

1115 Dunlap Road

Anderson, SC 29621

P.O. Box 1424

Anderson, SC 29625

Phone: 864-225-0792 | Fax: 864-226-3968