New Patient and Release and Televideo Consent forms with NPP and Copay

Richard L. Azrin, Ph. D.

Cheryl Millsaps Azrin, Ph. D.
Leslie Kahn, LCSW

Amber Fox , LPC
4260 Cahaba Heights Court Suite 180
Birmingham AL, 35243
Voice: (205) 329-7815,
Fax: (205) 329-7816

jamie.bhamneuro@gmail.com
www.brookwoodclinic.com

Please complete as much as possible of these forms.
You may skip any items that don't apply
Be sure to hit Submit at the bottom of the form, in order for us to get your answers.

Please sign all of the following 3 forms:

Form 1) The first form asks for your contact and insurance information.

Form 2) The second form asks who we can obtain information from and release information to.

Form 3) The third form gives us permission to do telephone or video calls with you.

Patient Name (First)*

(If your name is Senior or Junior please spell that out, but please DON'T use a period or comma in your name)

(Middle Name or Middle Initial)

(If your name is Senior or Junior please spell that out, but please DON'T use a period or comma in your name)

Patient Name (Last)*

(If your name is Senior or Junior please spell that out, but please DON'T use a period or comma in your name)

Email (Test results, receipts, and forms will be sent to this email address):

Confirmation Emailexample@example.com

Address

Street Address Line 2

CityState

Zip

Gender

MaleFemaleOther

Patient's Employer

Birth Date*

MonthDayYear

Age

Social Security Number

Patient Home Phone

Area CodePhone Number

Patient Work Phone

Area CodePhone Number

Patient Cell Phone

Area CodePhone Number

Marital Status

Driver License #:

Driver License: You may click on Take Photo below to take and send a photo of your license

Spouse/Partner Name

Spouse Soc Sec #:

Spouse place of Employment

Spouse Phone #:

Other Emergency Contact

Relationship to Patient

Emergency Contact Phone

Name of Primary Insurance:

Primary Insurance Contract #

Primary Insurance Group #:

Effective Date

Date

Primary Insurance Policy Holder's Name:

Primary Insurance Policy Holder's Date of Birth

Date

Primary Insurance Policy Holder's Soc Sec Number

Primary Insurance Holder's Relationship to Patient

Primary Insurance Policy Holder's Employer

Primary Insurance: Please give all Phone Numbers:

Insurance Card: You may click on Take Photo below to take and send a photo of your card

Do you have a Secondary Insurance

NoYes

2) Name of Secondary Insurance:

Secondary Insurance Contract #

Secondary Insurance Group #

Secondary Insurance Effective Date

Date

Secondary Insurance Policy Holder's Name

Secondary Insurance Policy Holder's Date of Birth

Date

Secondary Insurance Policy Holder's Soc Sec Number

Secondary Insurance Holder's Relationship to Patient

Secondary Insurance Policy Holder's Employer

Secondary Insurance: Please give all Phone Numbers:

Area CodePhone Number

Can we contact you at the address, phone, or email that you listed above?

YesNo

Request for Confidential Handling of Health Information
Complete alternate contact information below only if you want communications regarding your health care information sent to an alternate address or telephone or email, other than listed above. I request that my provider handle my confidential health information as described below. All reasonable requests to receive communication of your health information by alternative means and/or locations will be granted. Please describe the alternative means below (e.g. US mail, telephone call, Email, etc.) by which you prefer to receive your health information.

Alternate Telephone (if needed)

Area CodePhone Number

Alternate Address (if needed)

Alternate Telephone (if needed)

Alternate Email (if needed)

example@example.com

Agreement
If your insurance company OR health plan requires pre-approval OR referral for your visit, it is your responsibility to obtain this referral or YOU will be personally responsible for the bill. I, the undersigned (patient or legal guardian), authorize medical treatment to be rendered by the provider and assume financial responsibility. In the event the account is not paid in full within 90 days*, the undersigned agrees to pay all costs of collection including reasonable attorney fees, and hereby waives all rights of exemption under the constitution and laws of the State of Alabama. I also authorize the release of my medical records to my physicians and insurance carriers. If the provider has a contractual arrangement with your insurance carrier, the balance refers only to the amount that you are required to pay. I understand that all of the providers in the offices at 4260 Cahaba Heights Court, Suites 180-182, Vestavia, AL 35243 are independent practitioners (not partners) although they are sharing office and staff. Your signature below also indicates you have seen or received the Alabama Notice Form: Notice of Policies and Practices to Protect the Privacy of your Health Information and agree to its terms and serves as an acknowledgement that you have been shown or given a copy of the HIPAA Notice Form.
COMMUNICATION REGARDING MY ACCOUNTS: Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts from any services and any collectors of my accounts, through various means such as 1) any cell, landline, or text number that I provide, 2) any email address that I provide, 3) auto dialer systems, 4) Voicemail messages, and other forms of communication.
Informed Consent: I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.

Signature of Patient or Responsible Party:*

Date Signed

DateHourMinutesAM/PM Option

If signed by a responsible party, describe that representative's authority to act for the patient

Patient Name (First)

Patient Name (Last)

Birth Date

Date

Social Sec. #

When we ask doctors to send us your records, what years should we request?

Do you have detailed restrictions you insist on adding about releasing information?

No, I do not need to specify additional detailed restrictions.Yes

Please list any restrictions on this release of information (you must also speak to someone in our office and verify that providers, and especially that staff understand and are able to agree your restrictions):

DO NOT LIST YOUR OWN NAME BELOW.

PLEASE LIST FAMILY, DOCTORS, OR HOSPITALS YOU WOULD LIKE ME TO OBTAIN INFORMATION FROM AND RELEASE INFORMATION TO.

To allow the report to be sent to the referral, please enter the Referral Name here, or write Do Not Release to Referral:*

Name of Doctor or Person or Facility authorized to obtain and to release information (list your family, Doctor, hospital or facility, other individuals or organizations):

Name of Doctor or Facility usually goes here (release/obtain records)

Phone (if you have it)

Fax (if you have it)

Address (if you have it)

City

State

Zip

Is there a 2nd individual or organization that we need to get or give information to?

YesNo

2nd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone (if you have it)

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 3rd individual or organization that we need to get or give information to?

YesNo

3rd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone (if you have it)

Fax (if you have it)

Address (if you have it)

City

State

Zip

Is there a 4th individual or organization that we need to get or give information to?

YesNo

4th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone (if you have it)

Fax (if you have it)

Address (if you have it)

City

State

Zip

Is there a 5th individual or organization that we need to get or give information to?

YesNo

5th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone (if you have it)

Fax (if you have it)

Address (if you know it)

City

State

Zip

Name of patient and/or responsible party signing below:

Signature of patient or responsible party*

Date

DateHourMinutesAM/PM Option

If signed by patient's representative, please provide a description of representative's authority to act for the patient:

Teletherapy Video and Audio Consent Agreement
I understand that telehealth or teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when they are located at a different site than the provider; and hereby consent to receiving health care services to me via telehealth over secure video conferencing platform. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to telehealth or teletherapy. I understand that while telehealth or teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective. I understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the health care provider is not responsible for any technical problems and does not guarantee that services will be available or work as expected. I understand that I am responsible for information security on my computer and in my own physical location. I understand that I am responsible for creating and maintaining my user name and password and not share these with another person. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my conversation. I understand that my health care provider or I can discontinue the telehealth/ teletherapy services if it is felt that this type of service delivery does not benefit my needs. I have read and understand the information provided above regarding telehealth or teletherapy, have discussed it with my health care provider or office staff and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth or teletherapy in my care.

Name of Patient or Name of the legal representative signing below:

Signature*

Date Signed

DateHourMinutesAM/PM Option

If you don't know your copay, please call 205-329-7815 from 8am-noon or from 1pm-4pm to pay your copay before your upcoming visit.

IF YOU DON'T KNOW YOUR COPAY DO NOT ENTER CREDIT CARD INFORMATION

If you have any other records or information you would like to send to us, you may upload them here by clicking on the Browse Files button below:

Browse Files

Amber Fox, LPC

Amber Fox LPC

Notice of Privacy Practices may be viewed here, and will be emailed to you after you submit this document:

Form 1: New Patient Information

Form 2: Release of Information

Form 3: Consent for Teletherapy, Video, and Audio