I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Delaware Behavioral Health all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
I will arrive in time for my appointments during the period previously scheduled with the office staff. If I cannot attend, I will notify the office 24 hours ahead of time and I understand that missing my appointment without giving proper notice may result in a $50 fee or termination from this practice. I agree that while under the care of my prescribing Nurse Practitioner, I will disclose the medications currently prescribed to me as well as any other information relevant to my mental health treatment. I will be forthcoming regarding my healthcare as a whole and I will not take psychiatric medications from any other prescriber. Using my medication for any reason not in compliance with the treatment plan intended by the Nurse Practitioner will likely result in the termination of my relationship with Delaware Behavioral Health, Inc. I will treat the staff in this office with the dignity and respect that I would expect from others. I know that if my behavior does not meet this standard I will lose my right to continue treatment with Delaware Behavioral Health, Inc.
I consent to have Delaware Behavioral Health provide me psychiatric and mental health care.