ACPC Patient Packet

ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: office@adrianpsych.com
What type of services are you seeking?

Therapy/CounselingPsychiatric- Medication
Name
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Social Security Number: *
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
HOME PHONE:
CELL PHONE:
EMAIL
example@example.com
When we call you is it okay to leave you voicemail?

YesNo
Is it okay to leave a message if someone other than you answers your phone?

YesNo
Your Employer:
Employers Address:
Martial Status:

MarriedSingleDivorcedWidowedSeperated
Gender:
Parent or Spouse Name:
Family Physician:
Referred By:
INSURANCE INFORMATION
PRIMARY INSURANCE:*
POLICY # / MEMBER ID: *
GROUP #:
PRIMARY INSURANCE POLICY HOLDER INFORMATION:
Primary Insurance Policy Holder Name:
Primary Insurance Policy Holder Date of Birth:
Primary Insurance Policy Holder Address (If it is different from above):
Primary Insurance Policy Holder Employer:
Primary Insurance Policy Holder Employer City and State:
SECONDARY INSURANCE:
SECONDARY INSURANCE POLICY # / MEMBER ID:
SECONDARY INSURANCE GROUP #:
SECONDARY INSURANCE POLICY HOLDER INFORMATION
Secondary Insurance Policy Holder Name:
Secondary Insurance Policy Holder Date of Birth:
Secondary Insurance Policy Holder Address:
Secondary Insurance Policy Holder Employer:
Secondary Insurance Policy Holder Employer City and State:
DISCLAIMER:

THE PRACTITIONERS AT ACPC ARE INDEPENDENT OF EACH OTHER IN THEIR PRACTICE OR PROFESSIONAL SERVICE. CLAIMS, EITHER IMPLIED OR EXPRESSED, AGAINST THE CLINIC OR THE PRACTIONERS WILL NOT BE ADDRESSED OTHER THAN THOSE BETWEEN THE PATIENT AND HIS/HER COUNSELOR/NP, PA OR PSYCHIATRIST.

I CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF THESE SERVICES AND AGREE TO PAY THEM IN FULL AT THE TIME OF SERVICE, UNLESS OTHER ARANGEMNTS HAVE BEEN MADE WITH MY INSURANCE OR PROVIDER. I ALSO CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF MISSED APPOINTMENTS WHEN NO NOTICE OF CANCELLATION IS MADE 24 HOURS IN ADVANCE. I ALSO CONSENT TO PAYMENT FOR A FEE OF $50 IF COLLECTION ACTION IS NECESSARY TO COLLECT ON ANY UNPAID BALANCES ON MY ACCOUNT.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
Patient Name:
Date of Birth:

MonthDayYear
Date
AGE:
Preferred Pharmacy:
Location of Pharmacy:
Current Medications

Please list all medications you are currently taking. Including controlled medications. If taking more than 6 medications email a list to the office.
Medication #1:
Dosage:
How Often?
Medication #2:
Dosage:
How Often?
Medication #3:
Dosage:
How Often?
Medication #4:
Dosage:
How Often?
Medication #5:
Dosage:
How Often?
Medication #6:
Dosage:
How Often?
Any allergies to medications?

YesNo
If yes, Please list them:
Any allergies to food?

YesNo
If yes, Please list them:
Do you Smoke?

YesNo
If yes, How many years?
If yes, How many packs a day?
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
Please check off appropriate boxes.

This gives our office the authorization to bill your insurance company or bill you as a cash pay.
I authorize use of this form on all my insurance submissions.*

YES
I authorize release of information to all my insurance companies.*

YES
I understand that I am responsible for my bill. (Cash pay, Deductible and Copay).*

YES
I authorize my doctor to act as my agent in helping me obtain payment from my insurance company.*

YES
I authorize direct payment to my doctor.*

YES
I permit a copy of this authorization to be used in place of the original.*

YES
Do you authorize release of information to relevant Health Care Providers including your Primary Care Physician?

YESNO
Patient Name:*
Signature (patient, parent, guardian)*

Clear
Date*

MonthDayYear
Date
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
Health insurance Portability & Accountability Act (HIPPA) Privacy Acknowledgment Form

I have received a copy of the Adrian Counseling & Psychiatric Clinic mental health privacy notice. I understand that the privacy notice contains information that will help me get any questions I have answered regarding my privacy and provides me with the information to file a complaint related to the use of my protected health information.
Patient Name:
Signature (patient, parent, guardian)*

Clear
Date*

MonthDayYear
Date
IMPORTANT NOTICE TO ALL PATIENTS
IT IS YOUR RESPONSIBILITY TO KNOW YOUR INDIVIDUAL INSURANCE POLICY. MANY INSURANCE POLICIES HAVE EXCLUSIONS. MOST HAVE DEDUCTIBLES, CO-PAYMENTS AND CO-INSURANCE. SOME INSURANCE POLICIES MAY NOT COVER OUR SERVICES.

IT IS IMPORTANT FOR YOU TO CHECK WITH YOUR INSURANCE CARRIER TO DETERMINE IF THE PROVIDER YOU ARE SEEING IS LISTED AS AN "IN-NETWORK" PROVIDER. IF THEY ARE NOT LISTED AS AN 'IN-NETWORK" PROVIDER YOU MAY HAVE A HIGHER DEDUCTIBLE AND/OR CO-PAY.

REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR ALL BILLS NOT COVERED BY YOUR INSURANCE POLICY.
Patient Name:
Signature (patient, parent, guardian)*

Clear
Date*

MonthDayYear
Date
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
Authorization for Release of Information to

Family Members
Patient Name:
Date of Birth:

MonthDayYear
Date
Many of our patients allow family members such as their spouse, parents, or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize Adrian Counseling and Psychiatric Clinic to release my medical and/or billing information to the following individual(s):
1.
Relationship to Patient:
2.
Relationship to Patient:
3.
Relationship to Patient:
I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. You have the right to revoke this consent in writing at any time.
Patient Name:
Signature (patient, parent, guardian)

Clear
Date

MonthDayYear
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
Patient Fees and Payment Agreements

We bill usual and customary fees for standard services offered.

Additional services not covered by insurance companies:

FMLA, Long term medical leave and other forms. $50

Medical leave, Short term (less than 7 days). $10

Late Cancel or No-Show fee without a 24-hour notice. $50

Medication refills without an appointment. $10

Returned check fee. $35

Medical record copying will charge according to State of Michigan rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider.

I understand there will be a $35.00 fee for any returned checks. I also understand that Adrian Counseling and Psychiatric Clinic reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged and additional $50.00.

I understand it is my responsibility to keep scheduled appointments or notify Adrian Counseling and Psychiatric Clinic staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and we cannot bill your insurance carrier.

Fees are subject to change without notice.
PRIVATE PAY

For patients not utilizing insurance, usual and customary fees of Adrian Counseling and Psychiatric Clinic apply unless a different rate is listed below.

I HAVE READ, UNDERSTAND AND AGREE WITH THE FINANCIAL CONDITIONS DESCRIBED ABOVE.
Patient Name:
Signature (patient, parent, guardian)*

Clear
Date*

MonthDayYear
Date
ACPC, PLLC

142 East Maumee Street, Suite 3

Adrian Mi 49221

Phone: 517-263-5810 Fax: 517-438-8193

Email: info@adrianpsych.com
TELEPSYCHIATRY PATIENT CONSENT FORM
Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.

The potential benefits of telepsychiatry are:
- ```
Reduced wait time to receive psychiatric care.
```
- Aoiding the need to travel to a psychiatrist.
The potential risks of telepsychiatry include, but are not limited to:
- There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session.
- Pure Psychiatry of Michigan utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions.
Alternatives to the use of telepsychiatry:
- Traditional face-to-face sessions.
I understand that I have the following rights with respect to telepsychiatry:
- The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment isconfidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
- I also understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.
- I understand that there arerisks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
- In addition, I understand that telepsychiatry based services and care may not be as complete as facetoface services. I also understand that if my psychiatrist believes I would be better served by another form of psychiatric services (e.g. faceto face services) I will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry
- I understand that I have a right to access my medical information and copies of medical records in accordance with Michigan Law, for a $10.00 fee
Patient’s Responsibilities

• I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.

• I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.

• I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.

• I understand that my psychiatrist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.

• I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to- face visit, or a second telepsychiatry visit.

• I understand that post COVID-19 it is my responsibility to contact my insurance company to verify telepsychiatry coverage.

By signing below, I confirm that I have verified my behavioral health benefits with my insurance company and that telehealth is a covered benefit under my insurance plan. If not, I understand that I am responsible for the cost of any telehealth visit not covered by my insurance company.

Patient Consent to The Use of Telepsychiatry:

I hereby consent to engaging in telepsychiatry with Adrian Counseling and Psychiatric Clinic as part of my psychiatric evaluation and treatment. I understand that "telepsychiatry" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.
Patient Name:
Signature (patient, parent, guardian)*

Clear
Date*

MonthDayYear
Date

INSURANCE INFORMATION

PRIMARY INSURANCE POLICY HOLDER INFORMATION:

SECONDARY INSURANCE POLICY HOLDER INFORMATION

Current Medications

IMPORTANT NOTICE TO ALL PATIENTS

TELEPSYCHIATRY PATIENT CONSENT FORM

Please add photos of your insurance card and photo ID

Please ensure photos are not blurry, otherwise your appointment request can be delayed, thank you.