Place a check next to any illness or condition that your child has had. When you check an item, also note the approximate date (or age) of the illness

Place a check next to any illness or condition that any member of your family has had. When you check an item, please note the member's relationship

The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a question mark. If you don't remember the age at which the behavior occurred, please write a question mark.

What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to each technique that you usually use?

Child & Adolescent Patients: Follow up Appointment: Paperwork/Phone call:

• Two sessions at $200 per session (These are 60 minutes sessions.)
  $150 for 30 min follow up sessions. If sessions go over 30 minutes, $200
  $200 per hour for requested activities outside of scheduled appointment times.

Payment for services or co-pays are expected at the time of service, either cash, check or credit card (not CareCredit though)

I am a provider for: Aetna, Cigna, First Health (includes Coventry), HealthSmart (includes AHPO, Emerald and Interplan), Humana, Medical Mutual of Ohio, OhioHealthy, Ohio Health Choice, and Selis Healthcare,)includes Ohio Preferred Network [OPN]). Patients will have bills for service sent to the insurance company on their behalf. All others are expected to pay for the service, in its entirety, at the time of each appointment. You will be given a voucher for that service which you may use to submit to your company in order to seek reimbursement directly from them. Please do not be surprised if they only reimburse a percentage of that bill, sometimes only 50 to 75%.

I will not be able to complete any paperwork or treatment plans required by insurance companies other than those specifically listed above. Paperwork completion will be performed at the rate listed above.

Cancellations and No-Shows:

*If you miss a scheduled appointment, or are unable to cancel 24 or more hours in advance, you will be charged $50 for a follow up appointment and $100 for one of the initial consultation appointments. (Your insurance company will not reimburse you for this. Exceptions to the 24-hour notice policy would include a specified emergency or if the appointment can be filled in your absence.)*

Confidentiality:

Everything that takes place in treatment is confidential and may not be released without your expressed written permission. There are two exceptions to this: if you or your child becomes a danger to self or others; and if you or your child is involved in child abuse. In these situations I am legally bound to break confidentiality in order to protect all involved.

Emergencies and After Hours:

My email will be checked frequently throughout the day and at least once on weekends, but usually much more often. I will respond promptly. Though voicemail is available, it is not preferred and generally responses will be via email whenever possible. If what you feel you need cannot be addressed via email, we will need to schedule an appointment for clinical care. If you have an emergency, you will need to call the Netcare Access Crisis Line: 614-276-2273 or go to your nearest emergency provider/emergency room.

 

I consent to Dr. Richards providing psychiatric medical care. I understand and agree with the policies described above. I also understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. If my account is more than 60 days in arrears, I authorize that pertinent billing information can be released to a professional service for purpose of collection of the outstanding balances.

This notice is being sent to you, to inform you that we are H.I.P.A.A. compliant, and to describe to you an "overview" of your privacy rights. The H.I.P.A.A. law was created for companies who now transfer your personal and medical information electronically (via the Internet, email, etc Our Statement to You: We acknowledge your right to your privacy and will abide by both the H.I.P.A.A. and Privacy Act laws and regulations, we understand the meaning of the word "confidential" and we respect your rights to your privacy. If you have any questions or you would like to exercise any of your rights described in this page, you must submit your request in writing to our H.I.P.A.A. manager; or you may call and leave a detailed message and our H.I.P.A.A. manager will get back to you as soon as possible. A full copy of the H.I.P.A.A. Law and regulations is located at our place of business for your review, or you can visit these Government web sites for further information: http://www.cms.hhs.gov/hipaawww.hhs.gov/ocr/hipaahttp://www.hhs.gov/ocr/hipaa/privacy.html

Notice: Our office is H.I.P.A.A. compliant and we are regulated by the Federal Privacy Act. Our Responsibility: The confidentiality of your personal health information is very important to us. All information kept in your file is confidential and will not be released unless we obtain written consent to do so and/or it is stated by the law that we may release this information without your consent. Please note: We participate in an organized healthcare arrangement through OhioHealth Group, Ltd. (OhioHealth Clinically Integrated Network or CIN. The CIN consists of an organized system of healthcare in which multiple covered entities participate. Through the CIN, we participate in joint activities that include utilization review, quality assessment and improvement activities, and certain payment activities. We may disclose your PHI to other participants in this organized healthcare arrangement in order to facilitate the healthcare operations activities of the CIN.

What we can do without your Consent: Under federal and Ohio law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. [However, the American Psychiatric Association's Principles of Medical Ethics or state law may require us to obtain your express consent before we make certain disclosures of your personal health information.] [If relevant: Participants in this organized health care arrangement also share health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the organized health care arrangement.] Examples of these are: Asking a nurse to assist with taking your temperature and to document the results or supplying your insurance company with a diagnosis or other related health information that will assist payment for services rendered. Supplying the billing department with demographic and diagnostic information, etc. Under Federal and Ohio State law, we are permitted to use and disclose personal health information without authorization, for treatment, payment, and health care operations. Note: If you are available, we will provide you an opportunity to object before disclosing any such information. If YOU are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our professional judgment to determine what is in your best interest regarding any such disclosure.

Instances where your consent is not needed. (examples)

• Appointment reminders and other health related services (this would include leaving messages on answering machines, unless directed not to
• Business Associates such as a Billing Company.
• Communicable Disease Control.
• Communications with family, only if they are the responsible party for your care and/or payment.
• Coroners, Medical Examiners, and Funeral Directors.
• Disaster relief or to assist in disaster relief efforts.
• Food and Drug Administration (FDA)
• Judicial or Administrative Proceedings.
• Law Enforcement

There are other instances where your PMI (Personal Medical Information) may be given out. But our office policy is to always try to get permission from you first before we disclose any such information. In general, our practice will only release actual medical information, such as a diagnosis, medications you have been prescribed. Length of treatment, etc. Session notes that document diagnoses, medications prescribed and the content of our sessions will only be released upon your signing of a specific release of information allowing the practice to share that information with those you designate. This is mostly done via fax. Please advise if this is not acceptable.

Your Health Information Rights: Under the law, you have certain rights regarding the health information that we collect and maintain about you. This includes the right to: (examples):

• Request that we restrict certain uses and disclosures of your health information. We are not, however, required to agree to a requested restriction.
• Request to review, or to receive a copy of, the health information about you that is maintained in our files and the files of our business associates (if applicable If we are unable to satisfy your request, we will tell you in the reason for the denial and your right, if any, to request a review of the decision.
• Request that we amend or update the health information about you that is maintained in our files. This does not include therapy notes however.
• Request a list of whom we sent your health information to.

Acknowledgment of Receipt of Notice of Privacy Practices.

I acknowledge and understand that Dr. Richards is abiding by the H.I.P.A.A., Ohio state and federal privacy act law(s) and regulations; and I hereby acknowledge that I have reviewed and/or received a copy of the Notice of Privacy Practices