Patient Registration Packet

Patient Registration Packet
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemaleOther
Mailing Address*

Address

Street Address Line 2

(City)State / Province

Postal / Zip Code
Physical Address (can put "SAME" as above unless it is a P.O. Box)*

Street Address

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email address*
example@example.com
Social Security Number*
Social Security Number
Patient Employer*
Insured's Employer*
Insured's Name*
Insured's Birth Date*

MonthDayYear
Date
Secondary Insured's Name
Secondary Insured's Birth Date

MonthDayYear
Date
Additional family members who have permission to contact us regarding appointments
Phone number we may use to contact you and leave messages*
Preferred method of appointment reminder*

CallTextEmail
All appointments not confirmed will receive a reminder call the day before appointment.

Emergency contact people that we may call without a release of information should you require emergency care or intervention regarding your safety.
Emergency Contact Name*
Emergency Contact Number*

Minor Client Information
First Guardian's Name

First NameLast Name
Employer
Relationship to client
SSN#
Personal Mailing Address
City
State
ZIP
Contact Number

Area CodePhone Number
Work Number

Area CodePhone Number
Second Guardian's Name

First NameLast Name
Employer
Relationship to Client
SSN#
Personal Mailing Address
City
State
ZIP
Contact Number

Area CodePhone Number
Work Number

Area CodePhone Number
Shared Custody

If a minor child has a legal custody arrangement, I agree to provide Willow Medical a copy of the custody agreement prior to start of treatment. I understand that ALL parties/ legal custodians of a minor must sign and consent to treatment.
Initial

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Upload Custody Agreement (if applicable)

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Consent to Treatment

I consent to be treated and/or have my child treated by Willow Medical and Wellness. I hereby consent to any treatment or clinic services rendered to the patient under the general and special instructions of the provider and authorize any emergency first aid pending the instructions from the attending provider. I understand that I am fully responsible for all charges and fees for services rendered to me by Willow Medical and Wellness. I will pay my co pay, coinsurance or deductible at the time of my appointment unless other arrangements have been made. I authorize payment by my insurance company to pay directly to Willow Medical and Wellness. I authorize Willow Medical and Wellness to release necessary information to my insurance company to receive payment of claims. If my insurance company has not made payment within 90 days, I will provide full payment for services rendered, unless other arrangements are made.
Initial Please: Consent to Treatment*

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Client or parent/guardian signature*

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Date*

MonthDayYear
Date
Client or parent/guardian signature

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Date

MonthDayYear
Date

Insurance Information
INSURANCE BILLING IS PROVIDED AS A COURTESY. PLEASE BE SURE YOU HAVE CONTACTED YOUR INSURANCE FOR ANY PREAUTHORIZATION REQUIREMENTS AND TO DETERMINE YOUR BENEFITS.

YOU ARE REQUIRED TO KEEP OUR OFFICE UP TO DATE WITH YOUR CURRENT INSURANCE. IF YOUR POLICY CHANGES OR YOU ADD ADDITIONAL INSURANCE WE MUST BE NOTIFIED. WE WILL NOT BILL FOR CHANGES OVER 90 DAYS OLD.

Please provide a copy of your medical insurance card (front and back) and a photo ID to our front staff. To send electronically, you may use our UPLOAD link to send this information directly and securely to our office.

Primary Insurance Information:
Insurance Company*
Policy Holder Name*
Policy I.D. #*
Group I.D.#*
Policy Holder SS #*
DOB*

MonthDayYear
Date
Relationship to client*
Secondary Insurance Information:
Insurance Company
Policy Holder Name
Policy I.D.#
Group I.D.#
Policy Holder SS#
Relationship to client
DOB

MonthDayYear
Date
Front of medical insurance card

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Back of medical insurance card

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Photo ID

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Medical Practice Commitments and Expectations
Welcome to Willow Medical & Wellness. Our primary goal is to provide all of our patients with the best care possible in an effective and efficient fashion. Establishing commitments and expectations at the start of our work together will ensure a mutually satisfying treatment relationship. Please review the following items and sign at the end of the document to indicate your agreement with the terms. If you have any questions or concerns, please let us know so that we may address them. Thank you.
Keeping Appointment

Keeping appointments is integral to the treatment process. We recognize that things can come up and sometimes make it difficult to keep your appointment. Please let us know of this as quickly as you can so that we can reschedule your appointment and offer that time to another client. We do ask for one business days’ notice (24 business hours) for a cancellation or rescheduling. (For example: If your appointment is Wednesday at 1:30pm we request that you call us by 1:30pm Tuesday. If your appointment is on Monday at 1:30pm and you need to call to cancel or reschedule please call by 1:30pm on Friday.) We consider a late cancelled appointment to be the same as a missed appointment.

Reminder calls are made as a courtesy and are not guaranteed. The fees for a missed appointment or late cancellation (NS) are as follows: $25 for first NS, $50 for second NS, $100 for the third NS. After three missed or late cancellations, the fee will increase to 100% of the appointment fee. It is ultimately up to each providers' discretion what to charge for no shows or late cancellations. It is our clinic policy to refer clients to other qualified providers when there have been three or more missed appointments or late cancellations. Should this occur, Willow Medical will be happy to provide referral names and contact numbers of alternative providers who may better suit your needs. If indicated, a provider may provide you with a 30-day supply of medications during your transition of care.
Initial Please: Keeping Appointments*

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Payment for Services

We require payment of the portion of your bill not covered by your insurance at the time of service. Once you have engaged our services, it is important to us that you are able to continue. If your financial situation changes, please let us know as soon as possible. We will attempt to work with you.

Returned checks will result in a charge of $25.00. If there are two returned checks on your account we will no longer be able to accept personal checks. If your account becomes over 60 days past due, we will expect you to set up a payment plan through our billing department. If your account is 90 days or greater past due, without significant effort to meet your obligation, we reserve the option to cease providing services for you. Late payment fees of 1.5% per month will be charged on all account balances 90 days or greater past due. This fee will be charged each month to all balances past 90 days even if you are making monthly payments. Legal means to secure payment will be considered if necessary. This may involve hiring a collection agency, although we prefer not to use this option. All fees associated with this will be charged to the client. If your account is sent to collections we will no longer be able to continue treatment.
Initial Please : Payment for Services*

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Non-covered Services or Charges

There will occasionally be charges that are not covered by individual insurance plans. These fees are your responsibility. We will attempt to bill insurance for all billable services, but if they are not payable by your plan you will be billed in full. Some of these services include but are not limited to telephonic services and on-line sessions
Initial Please: Non-covered Services or Charges*

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Prescription Medication and Refills Policy

We request four (4) business days notice for all medication refill requests. Please notify your pharmacy if you need a refill, and ask them to fax a refill request to our office. You may also call the clinic and leave a detailed message regarding which medication you would like your provider to call in for you. If problems arise, let us know. Controlled medications cannot be refilled early (such as stimulants, benzodiazepines).

Dr. Ha, Dr. Rader and Dr. Johnson are in the office Monday through Thursday. Refill requests that are made on Friday are often unlikely to be given to provider until the following Monday. Dr. Smith is in the office Tuesday through Friday. Refill request made on a Monday won't be seen by Dr. Smith until the following Tuesday at the earliest.

We respectfully request that you make every effort to plan accordingly.

Recently, medications shortages have been an issue. If you need your prescription resent to a different pharmacy that has your medication in stock, please email us or leave a detailed message of the exact medication,dosage, quantity, and pharmacy for us to resend your prescription. Planning ahead helps prevent you from running out of medications.

We are required by Alaska law to use the Physician Drug Monitoring Program (PDMP) when prescribing any controlled medication. It allows us to see all controlled medication that you have been prescribed in Alaska and other participating states. When you are an active patient receiving medications from a Willow Medical doctor for any medications, you are consenting to allow us to look up all medications prescribed to you by any provider. This tool is designed for your safety and helps us know all the medications you are being prescribed. This can help avoid any potential adverse medication interactions.
Initial Please :Prescription Medication and Refills Policy*

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Contacting the Clinic

You may reach us during business hours at (907) 222-0753. Our fax number is (907) 222-0754. Our hours of operation are Monday – Thursday 8:00 AM to 6:00 PM and Friday 8:00 AM to 5:00 PM. If we do not answer the phone during our regular office hours, we are either on the phone or away from the desk momentarily. Please leave a message and we will get back to you as soon as possible.

If you are calling after hours, please leave a message and we will get back to you the next business day. Please note that we are closed all major holidays and are often closed the day prior or the day after depending on what day of the week the holiday falls on.

If you are experiencing a life-threatening emergency please call 911 or precede to the nearest emergency room. For urgent after hour emergencies you can call "988" (a 24/7 Crisis Line for behavioral health emergencies), or call the Community Crisis Line, at (907) 563-3200. If you cannot safely wait, please go to the nearest emergency room.
Initial Please: Contacting Clinic*

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Purpose of Treatment

I understand that the purpose of my psychotherapy and/or pharmacologic treatment (if indicated) is for my personal emotional/ physical health & wellbeing. Treatment goals will be established between myself and my treatment provider during the intake process. My treatment is not intended to be used for litigation purposes.

I agree not to request that my provider release my medical records for litigation purposes. I agree not to call my provider to serve as a witness in any current or future litigation, unless a prior agreement is made between myself and my provider.
Initial Please: Purpose of Treatment*

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Collaboration of Care

Your providers may collaborate care between each other and with other providers in the office. The administrative staff may also be asked to coordinate care between clinicians in the office or outside of the office depending on what is needed, this may be calling other clinics for availability, sending referrals or requesting records as needed. No protected health information will be shared with outside providers without a signed ROI (unless obligated by law for issues that involve safety to self or others)
Initial Please: Collaboration of Care*

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Clinic Property

Willow Medical and Wellness is a smoke free property. Please refrain from smoking on the property. We also respectfully request that you refrain from bringing in any weapons onto the clinic premises as we do see children, adolescents, and many of our adult clients have significant trauma issues. If you have questions about this request, please bring this to the attention of your treating provider. Thank you.
Initial Please: Clinic Property *

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No Surprises Act

OMB Control Number [0938-1401]
Expiration Date [05/31/2025]

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call [907-222-0753].
Initial Please: No Surprises Act*

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HIPAA Notice of Privacy Practices

I hereby acknowledge receipt of Willow Medical & Wellness Notice of Privacy Practices. I understand that the Notice describes how my personal protected health information may be used and disclosed, as well as how I may gain access to my protected health information.
Initial Please: HIPAA Notice of Privacy Practices*

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Date*

MonthDayYear
Date
Client / Guardian Signature*

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I HAVE REVIEWED THE COMMITMENTS AND EXPECTATIONS DOCUMENT AND AGREE TO ABIDE BY THEM WHILE I AM WORKING WITH WILLOW MEDICAL& WELLNESS.
Should be Empty:

Patient Registration Packet

Minor Client Information

Insurance Information

Medical Practice Commitments and Expectations

Keeping Appointment

Payment for Services

Non-covered Services or Charges

Prescription Medication and Refills Policy

Contacting the Clinic

Purpose of Treatment

Collaboration of Care

Clinic Property

No Surprises Act

HIPAA Notice of Privacy Practices