Private Practice SPA/VMH- Patient Information and Consent Forms

Insurance Information
1 Insurance Plan2 Insurance Plans3 Insurance Plans
Primary Insurance Name:*
Ex: Moda, Providence, Medicare, etc.
Primary Insurance ID Number:*
Primary Insurance Group Number:*
If none, put N/A.
Patient Relationship to Insured:*
If "Patient Relationship to Insured" is other than "Self" please complete the following:
Primary Insurance Subscriber's Name:*
Name of person who pays for insurance or receives insurance through their employer.
Primary Insurance Subscriber's DOB:*

MonthDayYear
Date of Birth
Subscriber's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Name:*
Ex: Moda, Providence, Medicare, etc.
Secondary Insurance ID Number:*
Secondary Insurance Group Number:*
If none, put N/A.
Patient Relationship to Insured:*
If "Patient Relationship to Insured" is other than "Self" please complete the following:
Secondary Insurance Subscriber's Name:*
Name of person who pays for insurance or receives insurance through their employer.
Secondary Insurance Subscriber's DOB:*

MonthDayYear
Date
Subscriber's Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Third Insurance Name:*
Ex: Moda, Providence, Medicare, etc.
Third Insurance ID Number:*
Third Insurance Group Number:*
If none, put N/A.
Patient Relationship to Insured:*
If "Patient Relationship to Insured" is other than "Self" please complete the following:
Third Insurance Subscriber's Name:*
Name of person who pays for insurance or receives insurance through their employer.
Third Insurance Subscriber's DOB:*

MonthDayYear
Date
Subscriber's Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Billing Information
Self- I am the patient receiving treatment and am the one responsible for paying for treatment I receive.Other- patient receiving treatment IS NOT the one responsible for paying for treatment they receive.
If "other", please complete the following information:
Name:*

Last NameFirst NameMiddle Initial
Relationship to Patient:*
Ex: Parent, Spouse, Child, etc.
DOB:*

MonthDayYear
Date of Birth
SSN:*
Social Security Number
Gender Identity:*
Ex: Female, Male, Non-binary, Transgender, etc.
Mailing/Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
YesNo
Secondary Phone Number:
YesNo
Session Fee Agreement
My signature below indicates that I take full responsibility to pay for my treatment. I have received and read a copy of the Salem Psychiatric Associates and Valley Mental Health Session Fees Policy. I understand that I will be charged for appointments that are missed or cancelled with less than 48 hours’ notice as the insurance cannot be billed for missed appointments. Future appointments will not be made until my account balance is paid in full or a payment contract is made. I authorize Salem Psychiatric Associates and Valley Mental Health to turn over my account to a collection’s agency should I become 3 months in arrears and do not complete an honor a new contract with Salem Psychiatric Associates Valley Mental Health.

To be signed by the individual responsible for all charges not covered by insurance:
Signature (to be signed by the individual responsible for all charges not covered by insurance):*

Signature of person listed as RESPONSIBLE FOR CHARGES for this patient.
Signer's Name:*

First NameLast Name
Relationship to Patient:*
Ex: Self, Parent, Spouse, etc.
Date:*

MonthDayYear
I have reviewed the Fee Agreement and understand that I can request a copy at anytime. Initial here please*

Fee Schedule

This fee schedule is for informational purposes only. You will only be responsible for the allowed amount that will be specified by your insurance. Please note, this is not a full list. Please see our website for the full CPT charges list. www.salempsych.com / www.valleymental.com
Service/Charge
Intake Evaluation $390
Medical Management, Minor Complexity $120
Medical Management, Low Complexity $175
Medical Management, Moderate Complexity $250
Medical Management, High Complexity $350
Psychotherapy 16-37 min. $175
Psychotherapy 38-52 min. $245
Psychotherapy 53 min. or more $320
Family counseling with client $330
Family counseling without client $280
Behavioral Health Counseling (15 min) $75
Psychotherapy for Crisis (first 60 min) $290
Psychotherapy Add-on 16-37 min. $150
Psychotherapy Add-on 38-52 min. $250
Psychotherapy Add-on 53 min. or more $300
Additional Interactive Complexity $30
Additional Crisis Psychotherapy (additional 30 min) $135
Crisis Intervention Service $75
Case Management $60
Group Skills Training $49
Consultation $150
Family Consult $175
Group Psychotherapy $105
Skills Training $50
Screening Assessment $190
My initials below indicate that I have reviewed the Fee Schedule and understand that I can receive a copy of the Fee Schedule by calling 503-362-1999.*
Initials (person RESPONSIBLE FOR CHARGES for this patient)

Session Fees Policy

Acknowledgment Form
I, (First Last name)* have read, had the opportunity to ask questions about, and understand the following policies related to my care at Salem Psychiatric Associates and Valley Mental Health:
Cancellation Policy: My appointment time is reserved specifically for me. If I cannot attend, I must cancel at least 48 hours in advance to avoid a charge. If I cancel less than 48 hours before the appointment or fail to attend, I will be charged a $100 fee. Please refer to the Session Fees section for more information about scheduling appointments only after outstanding balances are paid.

Office Fees: Our office fees vary depending on the services provided. I have received a handout detailing the SPA/VMH charges and procedures. If not, I will request one.

Insurance Billing: If I have acceptable insurance coverage, the office will gladly bill my insurance as a courtesy. However, I understand that I am responsible for full payment for appointments, regardless of my insurance coverage.

Monthly Statements: I will receive monthly statements outlining any outstanding balances and will be mailed to the address listed in my chart. These statements will ensure transparency and keep me informed of any amounts due. I understand that I will need to contact the office if I do not want to receive a statement.

Payment Due Dates: All fees, co-pays, co-insurances, and deductibles are due at the beginning of each month for the previous month’s services.

Payment Options: We offer several payment methods for both in-office and virtual appointments:
You can keep a credit card on file for automatic payments.
You can pay online through your MYIO Patient Portal.
You can make a payment over the phone by calling our billing office at 503-877-2216

Outstanding Balances: If I have an unpaid balance, future appointments will not be scheduled until payment is made.

To schedule a new appointment, I can make a payment over the phone at 503-877-2216
Prompt payment will ensure uninterrupted medication management during my appointments.

Payment Arrangements: If I need to make payment arrangements due to special circumstances, I will contact the billing office prior to receiving treatment. Addressing financial matters in advance will help ensure the smooth continuation of my care.

Additional Fee Policies:

There is a $25 charge for any returned checks.
Unpaid balances will incur a 2% interest charge per month once past due.
If there is no payment plan in place and no payments are received after 3 months, my account may be referred to a collections agency.

I acknowledge and agree to the above policies to support my treatment at Salem Psychiatric Associates and Valley Mental Health
Signature (person RESPONSIBLE FOR CHARGES for this patient):*

Signature of person listed as RESPONSIBLE FOR CHARGES for this patient.
Signer's Name:*

First NameLast Name
Relationship to Patient:*
Ex: Self, Parent, Spouse, etc.
Date*

MonthDayYear

Automatic Payment Agreement
YesNo, I DECLINE
If YES please continue to fill out the rest of the form.

If DECLINED please sign and move on to the next page.
I, (First Last name) (cardholder name), authorize Salem Psychiatric Associates and Valley Mental Health to charge my credit card on file for the out-of-pocket expense for any visit(s) with the patient’s provider.
I, (First Last name) (cardholder name), understand that it is my responsibility to ensure that Salem Psychiatric Associates and Valley Mental Health has an accurate and up-to-date credit card on file for automatic payments
I, (First Last name) (cardholder name), understand that my card will be run on the first week of each month for any amount due for any visits from the previous month
Signature (person RESPONSIBLE FOR CHARGES for this patient):*

Informed Consent for Treatment
I understand that after the initial appointment (know as the intake) the medication prescriber reserves the right to not continue in a patient/provider relationship and I will be offered community resources to obtain care elsewhere if they feel that they will not be a good fit.

I also understand that at any time during my time at Salem Psychiatric Associates and Valley Mental Health, my prescriber has the right to mandate a therapist as part of my treatment plan, and I will have 90 days to obtain a therapist and actively attend sessions. I understand that I will be required to fill out a release of information so my medication prescriber may coordinate care. Failure to meet these requirements may result in a loss of medication services.

My signature below indicates that I have read the above information and am requesting mental health treatment from Salem Psychiatric Associates and Valley Mental Health or its subcontracted providers. I hereby consent to treatment. I understand that I can request a copy of the Notice of Privacy Practices at any time. I authorize this office to release any information necessary to expedite insurance claims to the insurance companies listed above or to any subsequent insurers, should my mental health insurance change. This includes information about psychiatric treatment and/or drug and alcohol treatment. This will include my diagnosis and, for some insurers, may also include my treatment plan or the full text of my chart.

Note: Individuals 14 years or older must provide written consent to treatment unless a court or other law authorizes someone other than the individual and/or parent to make treatment decisions (ORS 109.675).
Signature (to be signed by patient if PATIENT IS 14 YEARS OR OLDER and able to consent to treatment):*

NOTE: Individuals 14 years or older must provide written consent to treatment UNLESS a court or other law authorizes someone other than the individual and/or parent to make treatment decisions (ORS 109.675).
Signer's Name:*

First NameLast Name
Relationship to patient:*
Date*

MonthDayYear

Notice of Privacy Practices

Acknowledgment and Consent
I understand that Salem Psychiatric Associates and Valley Mental Health, (referred to below as “This Practice”) will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:
- make decisions about and plan for my care and treatment;
- refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
- determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
- perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in waiting/reception area.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By signing below, I agree that I have reviewed and understand the information above and that I have the right to request a copy of the Notice of Privacy Practices by calling 503-362-1999.
Signature (to be signed by patient IF PATIENT IS 14 YEARS OR OLDER):*

NOTE: Individuals 14 years or older must provide written consent to treatment UNLESS a court or other law authorizes someone other than the individual and/or parent to make treatment decisions (ORS 109.675).
Signer's Name:*

First NameLast Name
Relationship to patient:*
Date*

MonthDayYear

Service Animal Policy
Salem Psychiatric Associates (SPA) and Valley Mental Health (VMH) honors and respects the rights of individuals with service and therapy animals, including animals who assist those with disabilities and who provide emotional support. However, in recognition of the sensitivity of others and in order to maintain a comfortable and safe environment for all of our clients, we have put the following guidelines in place:

A Service Animal is one that performs specific tasks to assist a person with a disability. Other names for these animals include guide animal, hearing animal, mobility animal, medical alert animal and psychiatric service animal. Your rights regarding service animals are protected under the Americans with Disabilities Act (ADA).

A Therapy Animal provides therapeutic support to an individual with mental health concerns. Other names for these animals include "emotional support animals," "companion pets," or "comfort animals." Although we know the importance of these animal relationships, we do not permit them on the SPA/VMH premises as some patients react negatively to animals.

Please Note: In an an attempt to preserve the therapeutic atmosphere and the safety of SPA/VMH clients, any animal that exhibits aggressive or disruptive behavior will not be allowed on the premises.
YesNo
If you need to bring your service animal with you to your appointments at SPA/VMH, please provide the following information:
Service Animal's Name:
Type of Service Animal:
Type of service/task performed by the Service Animal:
By signing below, I certify that I have read, understand, and agree to the Service Animal Policy.
Signature (to be signed by patient IF 14 YEARS OR OLDER and able to consent to treatment):*

NOTE: Individuals 14 years or older must provide written consent to treatment UNLESS a court or other law authorizes someone other than the individual and/or parent to make treatment decisions (ORS 109.675).
Signer's Name:*

First NameLast Name
Relationship to Patient:*
Date*

MonthDayYear
Should be Empty:

Registration, Consent to Treatment, and Fee Agreement

Patient Information

Parent / Legal Guardian / Power of Attorney Information

Insurance Information

Billing Information

Session Fee Agreement

Fee Schedule

Session Fees Policy

Automatic Payment Agreement

Informed Consent for Treatment

Notice of Privacy Practices

Service Animal Policy