PATIENT DATA

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RESPONSIBLE PERSON

This section must be filled out by the Person or Party financially responsible for the treatment.

Please enter Parent/Legal Guardian/Legal Benefactor information:


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INSURANCE CARD INFORMATION

Primary Insured person
(Primary Insured Person Definition: The person who a contract holder (an employer or insurer) has agreed to provide coverage for, often referred to as a Primary member/subscriber. Everyone else is listed as a dependent i.e. spouse, partner, child)

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Secondary Insured person
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FBH WANTS TO UNDERSTAND DETAILS AND CONCERNS

Please select the patients 3 most important concerns to discuss on evaluation day


Is the patient seeking to transfer to FBH?

If YES, please describe in detail the reason for changing providers.

Example: Moving to new city, did not get along because of (fill in data), doctor moved away, doctor retired. etc


Is anyone in the patient’s family a current or previous patient of FBH?


Is the patient seeking treatment about to be discharged from a hospital?


Was the patient seeking treatment recently discharged from a hospital within the last year?


Does the patient have a history of Suicidal, Homicidal Thought(s), Plan(s) or Attempt(s)?


Does the patient have a history of Self Injury?


Has the patient seeking treatment had substance treatment?


Does the patient have a history of being a sex offender?


PRIVACY POLICIES


CALL BACK POLICY

Please do not complain about not getting call backs to your questions or clinical concerns if you are not allowing us to at least leave a message on an IDENTIFIED VOICEMAIL i.e. HI MY NAME is (State your name) please leave a message after the tone.

Otherwise, we have to leave a generic message and ask you to call us e.g. someone at your number may be a patient at FBH and should call with your HIPAA CODE for important information.

Thank you.


TELE MEDICINE POLICIES

Informed Consent for Telemedicine Services - Illinois Introduction:
Telemedicine is the practice of medicine that involves the use of electronic communications to diagnose or treat patients located in Illinois who are in different locations from their healthcare providers. Telemedicine also enables healthcare providers at different locations in Illinois to share individual patient medical information for the purpose of improving patient care.

By executing this form, I, as patient or patient’s legal representative, (“Patient”) consent to the utilization of telemedicine technologies in the course of my medical treatment and authorize Family Behavioral Health , its employed and/or contracted providers, including primary care practitioners, specialists, and/or subspecialists, its staff, and subcontractors (collectively “Providers”) to review, and exchange medical information about Patient for the purpose of Patient’s treatment via telemedicine.

I understand that Patient medical information may be used by Providers for diagnosis, therapy, follow-up and/or education, and may include, but not be limited to, any of the following:
* Evaluation of Patient and Patient medical records;
* Evaluation of Patient diagnostic and laboratory test results;
* Live two-way audio and video recordings of Patient and Providers;
* Billing; and
* Output data from medical devices and sound and video files of Patient communications.


Possible Risks of Telemedicine Services:
As with any medical procedure, there are potential risks associated with the use of telemedicine technologies in treating patients.
While these risks will vary with the type of treatment obtained by Patient, they generally include, but may not be limited to:
* The Provider or on-site consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the Patient and Physician, or at least a rescheduled video consult between the Patient and Physician;
* Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment used in a telemedicine encounter; * In rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
* In rare cases, a lack of access to complete medical records may result in treatment delays, adverse drug interactions, allergic reactions, or other judgment errors.

INFORMED CONSENT FOR TELEMEDICINE SERVICES

By signing the I AGREE TO THE INFORMED CONSENT FOR TELEMEDICINE SERVICES this form, I, as Patient, acknowledge and affirm that I understand the following and consent to treatment via telemedicine services:
1. Not all conditions are appropriate for diagnosis and/or treatment via Telemedicine;

2. Telemedicine services, unlike direct in-person health care, are provided without direct, physical contact between a patient and healthcare provider and therefore present additional risks, including but not limited to, the risks listed above as well as failure to identify relevant symptoms, failure to diagnose or timely diagnose a condition, time delays between diagnosis and obtaining appropriate treatment requiring physical contact with a provider, and disruptions in care due to technological failures;

3. Patient is aware that alternatives to a telemedicine consultation are available and Patient will have an opportunity to discuss them and concerns with Provider when initiating telemedicine services;

4. The types of activities that are permitted using telemedicine services are limited by state law, insurance, payor source, and the practicalities of a patient’s condition, but generally include patient evaluation, diagnosis, treatment, prescribing medications (other than controlled substances and, for other legend drugs, only in the limited circumstances permitted by applicable federal and state law), obtaining laboratory results, scheduling appointments, providing health care information, and clarifying medical advice;

5. That the telemedicine services may not be billed to or covered by my insurance or any other third party payor and I may be required to pay out of pocket;

6. If I am in a clinic or other facility when seeking services via telemedicine, Provider may collaborate with an on-site clinician to perform the telemedicine services, and it is known and understood that Provider may not be informed of the clinician’s knowledge, experiences, and qualifications in rendering such care and makes no representations or warranties regarding such on-site clinician’s qualifications;

7. The quality of transmitted audio/visual communications and related data may affect the quality of services provided by Provider and may result in a disruption of care outside the control of Family Behavioral Health or Provider. Patient assumes the risk for such a disruption of care and agrees, as a condition to accepting services via telemedicine, that neither Family Behavioral Health or Provider is liable for any injuries or damages resulting from such a disruption.

8. IN THE EVENT THAT COMMUNICATIONS ARE DISRUPTED DURING TREATMENT VIA TELEMEDICINE, PATIENT WILL CONTACTYOUR PRIMARY CARE PROVIDER FOR NON-EMERGENCIES. IN THE EVENT OF A EMERGENCY. INCLUDING BUT NOT LIMITED TO A MEDICAL EMERGENCY OR DISRUPTION DURING TREATMENT VIA TELEMEDICINE CONSTITUTING AN EMERGENCY, PATIENT IS DIRECTED TO AND AGREES TO CALL THEIR LOCAL EMERGENCY DISPATCH (USUALLY 911) FOR FOLLOW-UP, INPERSON MEDICAL CARE, AS APPROPRIATE;

9. Information may be lost due to technical failures, for which Provider, Family Behavioral Health, and their respective affiliates shall not be held liable;

10. My healthcare information may be shared with other individuals for scheduling, billing, laboratory services, or other related purposes as permitted by HIPAA and other applicable federal and state laws and regulations, and I will provide the name and contact information for a physician of my election for medical records to be forwarded for follow-up care;

11. Patient controls the location from which he/she seeks telemedicine services and assumes the risk of a breach of his/her privacy (i.e. being overheard) by a third party during the telemedicine services.

12. If Patient permits, one or more on-site providers may be present during the consultation in order to operate the telemedicine equipment or assist in rendering services to Patient and will be directed by Provider, at the initiation of telemedicine services, to at all times maintain the privacy and confidentiality of the patient information obtained. To the extent Provider is aware of an on-site provider’s presence, Patient will be informed of their presence in the consultation and will have the right to request the following:
(1) to omit specific details of my medical history/physical examination that are personally sensitive to me;
(2) to ask non-medical personnel to leave the telemedicine examination room; and/or
(3) to terminate the consultation at any time. To the extent Patient permits another person to be present with or overhear Patient during telemedicine services, neither Provider nor Family Behavioral Health or their affiliates shall be liable for such person’s subsequent knowledge, use of, or sharing of Patient’s protected health information or violation of Patient’s privacy and confidentiality rights;

13. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine, and no information obtained in the use of telemedicine which identifies Patient may be disclosed to a third party without Patient’s written consent except in a care emergency or as otherwise permitted by applicable law;

14. Systems used for the electronic communications will incorporate network and software security protocols to protect the confidentiality of patient information and imaging data, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

15. Despite the security precautions taken by Provider, there is a risk that security protocols could fail, causing a breach of privacy of personal medical information;

16. Telemedicine services may not be provided solely via a phone call, text message, or written correspondence with a provider;

17. Outcomes of this telemedicine consultation cannot be guaranteed or assured; and

18. I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

Signatures/Concent

Patient Consent to the Use of Telemedicine By siging the INFORMED CONSENT FOR TELEMEDICINE SERVICES form, I, as Patient or Patient’s authorized legal representative, hereby give informed consent for the use of telemedicine in Patient’s medical care under the terms and conditions described herein, to receive medical treatment through telemedicine, and verify that Patient or Patient’s authorized legal representative has:
1. Read the whole consent form and fully understands the information provided above regarding telemedicine, including its benefits and risks;

2. Consent voluntary and with informed decision regarding the use of telemedicine services;


FINANCIAL POLICIES

Family Behavioral Health will accept cash payments as well as most insurances and will work with your insurance company to seek payment through electronic, paper or whatever HIPAA appropriate method required, per insurance rules. However, patients are ultimately financially responsible for paying all fees owed to Family Behavioral Health. Missed or late cancel appointment fees will be processed the day of the appointment. Any fees which are not paid in timely fashion, whether by insurance or by the patient, may incur late fees and may be assigned over to a third party agency for collection. An additional 40% fee may be added to all accounts sent to collection. This document authorizes Family Behavioral Health to keep the undersigned patient's financial policy and signature on file and to charge the credit card number on file for any fees due and owing Family Behavioral Health. This includes any property that you may damage or property that is borrowed and not returned.

In an effort to treat all patients equally and fairly, all patients are required to complete the financial policy form in order to continue care at FBH, even if there has not been a history of appointment/billing non-compliance for your account. Please inform us of any changes to your credit card status promptly.

On occasion FBH and/or one or more of its employees may be requested or required pursuant to court process (such as subpoena) to spend time preparing for and participating litigation/arbitration/mediation proceedings. This includes meetings, telephone calls, depositions, responding to subpoenas and in court testimony. FBH will charge the patient for such time, unless all of the fees are paid by another person or entity. The rate will be as follows: 1) general administrative time - $100/hour, 2) M.D. time - $1,000/hour, and provider other than M.D. time $500/hour. All such amounts are due within 14 days of invoice except initial two hours, which payment is due in advance to any services.

Appointment Cancellations are are required no later than: 48 hours in advance of your scheduled appointment clinic day. That means the start of the Clinic Day @ 8 am. Our voice mail system has a time/date stamp so please leave a voice message when you call and we will know that you called by 8 am even when no one is available to take your call. Example: Your Appointment is on Wednesday "Anytime that day." You call no later than 8 am Monday which is at the Top of the Clinic Day 48 hours in advance to Wednesday. This will give our staff and other patients plenty of time to reschedule that clinic space. This is beneficial for every patient at FBH. It gives everyone the best chance of being able to see their therapist of choice and get into to see the doctor. Late cancels ($75 fee/ appointment) Missed appointments ($100 fee/ appointment) will be charged the day of the scheduled appointment. Patients are able to leave messages for our FBH providers before appointments on the FBH 24 hour dedicated voicemail system which has a time stamp. Our reception team will relay your concern(s) to any provider during working hours. Medication Refills should be requested at your appointment with our reception team. If there are refills listed on your current prescription bottle, please contact your pharmacy directly. If there are No refills on your current medication bottle, please contact our office directly 1 week in advance and leave a message on our convenient prescription refill line 815-254-7400. FBH Only accepts refill requests directly from established patients with the HIPAA SECURE Codes. Late cancels ($75 fee/ appointment) and missed appointments ($100 fee/ appointment) will be charged the day of the scheduled appointment.

NOTE: Any returned checks or declined credit cards will result in a $75 fee depending upon what the bank charges us, how many times the transaction was attempted, and person hours involved with helping address the problem.

How We Guarantee an Appointment Reservation
• FBH Provides proper disclosure of our cancellation policy and terms and conditions for reservation. Patients seeking evaluations need to make a $250 deposit or a VISA/Mastercard/AmericanExpress which will be billed the entire $250 for missing their evaluation day. Prospective or current patients must give a 48-hour cancellation notice for new patient evaluations and multifamily member follow up sessions. Regular sessions, not multifamily, not evaluations require a 24-hour cancellation notice made the morning prior to the start of a regular clinic day. Not doing so equals a late cancel or no show (of course this can be done even 48 hours or greater before the appointment e.g., someone going on vacation lets us know one week in advance). The credit card will be charged for the appointment being missed.

• We will Obtain VISA/Mastercard/AmericanExpress account numbers from the cardholder to guarantee reservation, and authorization at the time of booking. Refunds can only be made on the same card number.

• By signing this form you the cardholder signify understanding of your reservation details and having received appropriate disclosures of reservation conditions at time of reservation. FBH is providing higher than standard of care service. This is personalized private practice and FBH provides the filling appropriate payment guidelines to ensure good care and clinic systems of care. Please note that payment is due upon completion of service. All accounts that are delinquent will be sent to collections if over 30 days past due and no response to either face to face, verbal phone discussion, via voice mail, approved text messaging or past payment due invoices sent to the patient in their portal or to their home.

Your important card information is protected. Once this form is completed, it goes directly into our HIPAA SECURE SERVER!

Acknowledgement and Signature
I acknowledge receipt of the above information and recognize that by providing my initials below creates an electronic signature that has the same legal force and effect as a handwritten signature.


PAYMENT INFORMATION

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E-Signature

Please sign electronically below.
By signing this form you agree to all FBH Policies, as well as, being the person who has legal rights to request this new patient evaluation appointment.
You are also the person who is financially responsible for the appointment(s) and agree to the FBH Financial Policy data located under the About page menu tab.
Also understand my HIPAA Rights described in FBH's Policies.

Please Note: By filling out this appointment it is not a guarantee of an appointment at FBH.
New Patient openings are based on immediate clinic and provider availability.
We thank you for your time and courage!

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