TNTMS New Patient Registration Packet

New Patient Registration Packet
Date*

MonthDayYear
Date
Client Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemaleOther
Address*

Address

Street Address Line 2

(City)State / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email address*
example@example.com
Patient Employer*
SSN*
Insurance Information

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.
Front of Insurance Card

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Back of Insurance Card

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Front of Photo ID

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Primary Insurance Company*
Primary Policy Holder Name*
Primary Policy Holder's Birth Date*

MonthDayYear
Date
Primary Policy ID #*
Primary Group ID #
Primary Policy Holder Relationship to client*
Secondary Insurance Company
Secondary Policy Holder Name
Secondary Policy Holder's Birth Date

MonthDayYear
Date
Secondary Policy ID #
Secondary Group ID #
Secondary Policy Holder Relationship to client
Insured's Employer
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.
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*

Consent to treatment
I consent to be treated by True North TMS at Willow Medical. 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 True North TMS at Willow Medical. 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 True North TMS at Willow Medical. I authorize True North TMS at Willow Medical 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.
Client or parent/guardian signature*

Clear
Date*

MonthDayYear
Date
Medical Practice Commitments and Expectations
Welcome to True North TMS at Willow Medical. Our primary goal is to provide all 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 fee for a missed appointment or late cancellation is 50% of the scheduled doctor appointment fee or $50 for the TMS treatment appointment. After three missed or late cancellations the fee will increase to 100% of the appointment fee.

It is our clinic policy to refer clients to other qualified providers when there have been two or more missed appointments or late cancellations in a 12-week period. Should this occur, True North TMS at Willow Medical will be happy to provide referral names and contact numbers of alternative providers who may better suit your needs. In certain situations, a provider may elect to provide you with a 30-day supply of medications during your transition of care.
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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.
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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
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Prescription Refills

We request four (4) business days notice for all medication refill requests. Requests made on Friday’s will not be reviewed until the following Monday. Please notify your pharmacy if you need a refill, and ask them to fax a refill request to our office. You may use our secure messaging link on our website or call the clinic to leave a detailed message regarding which medication you would like your provider to call in for you. If problems arise, please let us know. Certain medications cannot be faxed, phoned in, or refilled early (Scheduled II medications such as stimulants). Planning ahead helps prevent you from running out of medications.

Dr. Telford is only in the office on Fridays. Refill requests made on days that he is not in the office may be filled by a covering provider. Dr. Ha is in the office Monday through Thursday. Refill requests that are made on Friday are often unlikely to get filled until the following Monday.

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

You may reach us during business hours at (907) 344-0753. Our fax number is (907) 222-0754. Our front office hours of operation are Monday-Thursday 8:00 AM to 6:00 PM and Friday 8:00 AM to 5:00 PM. Our TMS treatment hours are Monday-Friday from 7:30 AM to 6:00 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 feel free to 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 the Community Crisis Line, at (907) 563-3200, call 911 or proceed to the nearest emergency room.
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Purpose of Treatment

I understand that the purpose of my Transcranial Magnetic Stimulation, 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 and I agree not to call him/her to serve as a witness in any litigation I am currently involved in or any litigation I become involved in, unless a prior agreement is made between myself and my provider.
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Clinic Property

True North TMS at Willow Medical 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.
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HIPAA Notice of Privacy Practices

I hereby acknowledge receipt of True North TMS at 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.

I HAVE REVIEWED THE COMMITMENTS AND EXPECTATIONS DOCUMENT AND AGREE TO ABIDE BY THEM WHILE I AM WORKING WITH TRUE NORTH TMS AT WILLOW MEDICAL.
Initial*

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Date*

MonthDayYear
Date
Client / Guardian Signature*

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Should be Empty:

New Patient Registration Packet

Consent to treatment

Medical Practice Commitments and Expectations

Keeping Appointment

Payment for Services

Non-covered Services or Charges

Prescription Refills

Contacting the Clinic

Purpose of Treatment

Clinic Property

HIPAA Notice of Privacy Practices