Practice Paperwork

Paperwork must be updated annually

P: (833) 336-7543 | F: 833-463-1803

info@bhealthyforlife.com | www.bhealthyforlife.com

Personal Information

This is not a HIPAA Compliant Platform | Sample Practice Paperwork

First name

Last name

Phone

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Birthday

SS#

Driver License

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Insurance Front

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Insurance Back

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Employer

Communication

I understand that SMS Text communication through cell service is not HIPAA compliant and agree that SMS text is the favored and most efficient method of communication for me. I agree to SMS text with BHealthy For Life, its associate and its affiliates. I have been given information about other protected means of communication and understand that texting does not protect my privacy rights. By my signature below I agree to SMS text messages.

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Your Signature

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Emergency Contact

Emergency Contact First & Last Name

Emergency Contact Phone

Client authorizes BHealthy For Life and it’s associates and affiliates to contact my emergency person including emergency services in cases of crises situations involving suicidal ideation, homicidal ideation and/or if I cannot be reached within 48 hours by other reasonable means.

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Insurance Information

Insurance Company

Primary Insured First & Last Name

Same as Above

Member ID

Group #

Birthday

SS#

Emergency Contact Phone

Employer

Select an Address

EAP Benefits are available and must be submitted by a form you get from your HR or Insurance Company.

Credit Card Authorization

EAP Form

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Name on Card

Card Number

Exp Date

CVC Code on Back

Zip Code

Credit Card Front

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Credit Card Back

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I hereby authorize and associates to charge my credit card for fees incurred which include fees for appointments, appointments missed or not canceled with 24-hr notice, copays or coinsurance, or fees for completion of paperwork requested or not part of a regular appointment, including extended phone contact, per office policy.

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Your Signature

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Notice of Privacy Policy:

This notice is being sent to you, to inform you that we are H.I.P.A.A. compliant, and to describe to you an "overview" of your privacy rights.

The H.I.P.A.A. law was created for companies who now transfer your personal and medical information electronically (via the Internet, email, etc.) As stated previously, we do not transfer any personal and/or medical documents electronically without your consent at this time and are not foreseeing doing this in the future.

Our Statement to You: We acknowledge your right to your privacy and will abide by both the H.I.P.A.A. and Privacy Act laws and regulations, we understand the meaning of the word "confidential" and we respect your rights to your privacy.

If you have any questions or you would like to exercise any of your rights described in this brochure, you must submit your request in writing to our H.I.P.A.A. manager; or you may call and leave a detailed message and our H.I.P.A.A. manager will get back to you as soon as possible.

A full copy of the H.I.P.A.A. Law and regulations is located at our place of business for your review, or you can visit these Government web sites for further information:
www.CMS.hhs.gov/hipaa
www.hhs.gov/ocr/hipaa

www.hhs.gov/ocr/hipaa/privacy.html

Notice:

Our office does not transfer "Personal Health Information" electronically; we are however H.I.P.A.A. compliant and we are regulated by the Federal Privacy Act.

Our Responsibility:

The confidentiality of your personal health information is very important to us. All information kept in your file is confidential and will not be released unless we obtain written consent to do so and/or it is stated by the law that we may release this information without your consent.

What we are allowed to do without your Consent:

Under federal and Ohio law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. [However, the American Psychiatric Association's Principles of Medical Ethics or state law may require us to obtain your express consent before we make certain disclosures of your personal health information.] [If relevant: Participants in this organized health care arrangement also share health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the organized health care arrangement.]

Examples of these are:

Asking a nurse to assist with taking your temperature and to document the results. Supplying your insurance company with a diagnosis or other related health information that will assist payment for services rendered. Supplying the billing department with demographic and diagnostic information, etc.

Under Federal and Ohio State law, we are permitted to use and disclose personal health information without authorization, for treatment, payment, and health care operations. Note: If you are available, we will provide you an opportunity to object before disclosing any such information. If YOU are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our professional judgment to

determine what is in your best interest regarding any such disclosure. Instances where your consent is not needed. (examples)

Abuse, Neglect, or Domestic Violence
Appointment reminders and other health related services (this would include leaving messages on
Answering machines, unless directed not to)
Business Associates such as a Billing Company
Communicable Disease Control
Communications with family, only if they are the responsible party for your care and/or payment

Coroners, Medical Examiners, and Funeral Directors
Disaster relief or to assist in disaster relief efforts
Food and Drug Administration (FDA)
Judicial or Administrative Proceedings
Law Enforcement

There are other instances where your PMI (Personal Medical Information) may be given out. But our office policy is to always try to get permission from you first before we disclose any such information.

In general our practice will only release actual medical information, such as a diagnosis, medications you have been prescribed. Length of treatment, etc.

Session notes that document diagnoses, medications prescribed and the content of our sessions will only be released upon your signing of a specific release of information allowing me to share that information with those you designate. This is mostly done via fax. Please advise if this is not acceptable.

Your Health Information Rights:
Under the law, you have certain rights regarding the health information that we collect and maintain about you.

This includes the right to: (examples)

Request that we restrict certain uses and disclosures of your health information. We are not, however, required to agree to a requested restriction.
Request to review, or to receive a copy of, the health information about you that is maintained in our files and the files of our business associates (if applicable). If we are unable to satisfy your request, we will tell you in the reason for the denial and your right, if any, to request a review of the decision.
Request that we amend or update the health information about you that is maintained in our files. This does not include therapy notes however.
Request a list of whom we sent your health information to.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge and understandBHealthy For Life and affiliates is abiding by the H.I.P.A.A., Ohio state and federal privacy act law(s) and regulations; and I hereby acknowledge that I have reviewed and/or received a copy of the Notice of Privacy Practices

Responible Party First & Last name

Responsble Party Is Same as Client

Responsble Party Is a Guardian

Responsible Party Signaturere

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Practice Policies

Bhealthy For Life, Affiliates & Therapists working in the clinic enjoy a collegial and educational professional relationship with several therapeutic disciplines within BHealthy For Life network. In your particular situation, your therapist works as an independently credentialed clinician through the Clinic and its affiliation BHealthy For Life Services will be billed to your insurance company via that relationship.

Sessions with therapists are by appointment only. The best way to contact your therapist is by calling their direct phone number or sending an e-mail to the email provided by him or her. Voice mail will be checked throughout the day and at least once in the evenings and on the weekends. Practitioners strive to respond to VM within 48 hours. In the event of an emergency, please contact Riverside Hospital Behavioral Health Emergency Services at (614) 566-5056, NetCare Access at (614) 276-CARE, 911 or 988.

Appointments are typically 50-60 minutes long. Missed appointments are not covered by insurance and may be paid out of pocket. There is a $75 no show fee if there is not 24 hours notice of a cancellation.

Payments & Insurance: Co-payments are due at the time of the appointment. Payments can be given to the therapist. We do not accept checks. If you are unsure about your balance or have any questions regarding billing, please contact Supervising practitioner Virginia Clagg at claggv@gmail.com.

Confidentiality: Everything that takes place in psychotherapy is confidential and may not be released without your expressed written permission. There are two exceptions to this: if you or your child becomes a danger to self or others; and if you or your child is involved in child abuse. In these situations, we are legally bound to break confidentiality in order to protect all involved. Confidentiality for children and adolescents in situations other than those listed above will be discussed with you during the evaluation phase of treatment.

By signing this document, I understand and agree with the policies described above. I also understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. If my account is more than 90 days in arrears, I authorize that pertinent billing information can be released to a professional service for purposes of collection of the outstanding balances.

Acknowledgment of Practice Policies

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Responible Party First & Last name

Responsble Party Is a Guardian

Responsble Party Is Same as Client

Your Signature

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Consent for Treatment

I give my consent to receive treatment and related services from Bhealthy For Life, its therapists, affiliates and partners and its collaborators. I understand that this consent is for the duration of the services provid

Minor Consent for Treatment

I give my consent as parent of guardian for the following individual to receive treatment and related services from BHealthy For Life, The Columbus Holistic Wellness Center and Recovery For Life its affiliates, partners and subsidiaries. I understand that this consent is for the duration of the services provided.

Responible Party First & Last name

Responsble Party Is a Guardian

Responsble Party Is Same as Client

Your Signature

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Release of Information

I hereby authorize My Practitioner, BHealthy, Recovery For Life and The Columbus Holistic Wellness Center the ability and authority to exchange protected private health information with the below organization.

Practitioner Name

Information can be shared with the below named entity:

Organization Name

Organization Address

Phone

Fax

Information to be Shared

Select all That Apply

Evaluation

Progress Notes

Treatment Update (may incldued rug and alcohol use)

For continuation of care

PROHIBITION ON REDISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS

PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS (42 CFR PART 2) PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IF HELD BY ANOTHER PARTY IS NOT SUFFICIENT FOR THIS PURPOSE. FEDERAL REGULATIONS STATE THAT ANY PERSON WHO VIOLATES ANY PROVISION OF THIS LAW SHALL BE SUBJECT TO PROSECUTION UNDER FEDERAL LAW. THE FEDERAL RULES RESTRICT ANY USE OF THIS INFORMATION TO CRIMINALLY INVESTIGATE OR PROSECUTE ANY ALCOHOL OR DRUG ABUSE PATIENT [52 FR 2 1809, June 9, 1987; 52 FR 4 1997, Nov. 2, 1987]

I understand that, unless action already has been taken in reliance on this authorization, I may revoke this authorization at any time by making a written request to my therapist & Affiliates. I understand that my therapist/ BHealthy For Life and its collaborators, affiliates, subsidiaries and partners may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is to enable the protected health information described above to be used for such research.

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Responible Party First & Last name

Responsble Party Is a Guardian

Responsble Party Is Same as Client

Your Signature

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Signature Witness

Telehealth Informed Consent

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure the integrity against intentional or unintentional corruption.Providers (our "Providers") are an addition to, and not a replacement for, your local primary care provider. We do not prescribe nor offer medical advice.

Service Limitations:

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your provider will make that determination.
OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

Possible Risks:

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
In very rare events, security protocols could fail, causing a breach of privacy of personal private information.

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

I hereby consent to receiving services via telehealth technologies. I understand that Providers offer telehealth-based behavioral health and mental health services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
I understand a licensed Provider will be assigned to me prior to the consult, however, I can request a different licensed Provider at any time. I can review the credentials of my assigned Provider.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand all medical reports resulting from the telehealth visit are part of my medical record.
I understand that BHealthy, Recovery For Life, The Columbus Wellness center, partners, subsidiaries and affiliates (The Organization) will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
I understand there is a risk of technical failures during the telehealth encounter beyond the control of. I AGREE TO HOLD HARMLESS The Organization AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that my Provider is not able to connect me directly to any local emergency services.
I understand that alternatives to telehealth consultation, such as in-person services are available to me.
I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for operational, quality assurance, scheduling and billing purposes. If I have a real-time consultation, persons may be present during the consultation other than the Provider during such real-time consultation in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
I understand that my Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
I understand that if I participate in a consultation, that I have the right to request a copy of my records which will be provided to me at reasonable cost of preparation, shipping and delivery within 30 days of notice.
I AGREE TO HOLD HARMLESS The Organization AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR ANY CLAIMS, LOSSES, OR DEMANDS CAUSED IN WHOLE OR IN PART BY THE USE OF A THIRD-PARTY TELEHEALTH SERVICEs.

By checking her you agree that you have read, understand and are cnsenting to the Telehealth Informed Consent

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Biopsychosocial Assessment (sample)

What brings you to therapy?

What is the goal of therapy?

List prior diagnoses:

Briefly describe your personal History with Mental Health/ Substance Use Disorder:

Personal history of Mental Health/ Addiction Treatment

口 None 口 Been to treatment 口 On MAT 口 Taking medications 口 Have Support

Anything else to know about personal History?

Briefly describe your family history of mental health/ substance use disorder:

Current Symptoms:

What symptoms have you had now or within the past 30 days? Select all that apply

口 Angry 口 Hearing things 口 Recurring Nightmares

口 Addiction 口 Hopeless 口 Relationship Issues

口 Anxious 口 Identity concerns 口 Restless

口 Cannot be in crowds 口 Impulsive 口 Seeing/ hearing things others cannot

口 Cannot concentrate 口 Lack of confidence 口 Self-harm

口 Cannot sleep 口 Lack of interest 口 Sleep changes

口 Compulsive behavior 口 Nervous 口 Sleep disturbances

口 Depressed 口 Obsessive thinking 口 Sleep too much

口 Disturbing thoughts 口 Obsessive Behaviors 口 Stress

口 Eating too much or too little 口 Panic attacks 口 Talk too fast

口 Fearful 口 Suspicious 口 Tired/fatigued

口 Feeling worthless 口 Poor memory 口 Trauma

口 Food/eating changes 口 Prefer being alone 口 Guilt

口 Grief/sadness 口 Night terrors

Additional Symptoms:

Addiction: . Highest Level of Education

口 Alcohol 口 Primary school

口 Opiates 口 High school 口 Graduated

口 Drugs _______________. 口 College 口 Graduated

口 MAT 口 Graduate

口 Gambling 口 Post Graduate

口 Pornography

口 Sex Career. Employment

口 Shopping 口 I love my job 口 I hate my job

口 Family history of addiction 口 My job is okay 口 I need a job

Relationships:

口 Single 口 Married 口 Divorced 口 Separated 口 It’s complicated 口Phobic

Marriage: