NEW CLIENT INTAKE FORM

The following documents are included:

• Intake (REQUIRED) Please complete EACH of the items. If the items do not pertain to you, please answer “N/A.,” “none,” or put a dash through the answer box.

• Guardian Authorization (REQUIRED) All persons who have custodial rights of the child MUST complete and sign the parental authorization form.

⇒ Divorced or separated parents:
If both parents do not have full custody, both parents will need to provide two parental authorization forms as well as a copy of the custody outline from the divorce/separation agreement.  We only ask that the parent submit the page(s) of the document that outline the custody rights of each parent as well as the signature page —not the entire divorce decree.

⇒ Foster parents or children in the Department of Children & Families (DCF) custody:
If the child is in custody of DCF, DBH requires an ROI signed by the DCF caseworker in order to provide treatment for the child.

• PCP Release of Information (ROI) (REQUIRED) An ROI authorizes DBH to request, obtain and/or exchange documentation with outside facilities. ***When requesting medical records, please note that facilities legally have 21 days to process the request. For some cases, DBH cannot schedule an appointment until we receive the requested records. Once we receive and review the requested records, we will contact you with next steps. ***
PLEASE NOTE THAT MANY FACILITIES ACCEPT ONLY THEIR SPECIFIC RELEASE OF INFORMATION FORM. PLEASE, CHECK THE FACILITY’S WEBSITE, OR CONTACT THEIR MEDICAL RECORDS DEPARTMENT TO ENSURE THAT YOU ARE COMPLETING THE CORRECT RELEASE
FORM.

• Consent to Treat (REQUIRED)- Authorizes DBH to provide treatment and/or take necessary actions to be able to provide treatment.

• Financial Agreement (REQUIRED) Responsibility of fees and charges for services provided by DBH.

• Consent for Telemedicine Services (REQUIRED) Authorizes DBH to use telemedicine in the course of your treatment.

• ID and Insurance Card (REQUIRED)- Please provide a copy of your government issued ID and the front and back of the child's insurance card.

Once completed please email the forms to intakes@danabehavioralhealth.org or fax to 781-465-7995 . If you fax any documents, please follow up with the Intakes Department by email or by phone to confirm our receipt of the documents.

Warmly,
DBH Intake Department

*Please complete EACH item below for the child seeking services.

For guardians who have split custody, shared custody, or otherwise, please refer to the guidelines on the instructions cover page for DBH’s documentation requirements.

Patient Authorization:

• I understand this authorization does not expire unless a written request is submitted to revoke authorization. Disclosure(s) made prior to receipt of revocation are authorized under the prior authorization.
• I understand that the confidentiality of my records is protected under Federal Regulations (42CRF, Part 2
• I understand that I may be charged for any case consultation that will occur between the listed provider above and my provider.
• I have read carefully and understand the above statements and do herein expressly and voluntarily consent to disclosure of the above information and/or medical records to these persons/agencies named above.

 

, and Dana Behavioral Health. If the client is a minor, parents please put your name above. By signing this form you hereby give permission for Dana Behavioral Health to provide treatment and take necessary actions to be able to provide treatment.

To provide treatment, Dana Behavioral Health will have to send medical records to your insurance company. You are responsible for the cost of services if your insurance does not pay or you do not have insurance.

By signing this form you are agreeing that you have read and understand our Patients Bill of Rights/ Responsibilities and Notice of Privacy Policies. You are agreeing to let us use your information, as well as send it to others in accordance with our written policies. Please make sure you have read and understand our Privacy Policies and Patients Bill of Rights/Responsbilities before signing this consent form.

In the future, we may change how we use and share your information and may change our Notice of Privacy Policies. If we do change it, you can find a copy on our website (www.danabehavioralhealth.org) or by calling us at (781) 429-7755.

If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we will comply with your wish.

After you have signed this consent, you have the right to revoke it (by writing and signing a letter telling us that you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may have already used or shared some of your information and cannot change that.

If you do not sign this consent form agreeing to our Notice of Privacy Policies and Patients Bill of Rights/ Responsbilities, we cannot treat you.

Payment for services provided by Dana Behavioral Health is due at the time of services rendered unless payment by health insurance has been arranged prior to the visit. If insurance coverage has been arranged, payment of any applicable copayment or deductible is due at the time services are rendered. If we do not have a contractual provider relationship with your insurance plan, full payment for services is due at the time services are provided. We will bill your insurance for you, and reimburse you if we receive payment. You agree to be fully responsible for payment of all services not covered by your insurance. If
there is a problem with your insurance coverage, you agree to pay your bill and handle any issues with your insurance company yourself.  As a courtesy to you, we will attempt to verify your insurance coverage and determine your insurance benefits. However, if your insurance company has misinformed us or you feel we have misinformed or failed to adequately inform you regarding your benefits,
you are still responsible for payment of all charges not covered by your insurance. We encourage you to verify your insurance benefits and coverage yourself and make sure that you fully understand your coverage. By signing this agreement you agree to be responsible for all charges for the client identified below, even if you believe another party should bear responsibility for these charges. Some services may not be covered by health insurance. You agree to be fully responsible for all services that are not covered by the health insurance plan. This may include charges for telephone consultation, written correspondence, or reports
in connection with a client’s evaluation or treatment, including consultation or correspondence with the client, family members, past or current treatment providers, educational professionals, attorneys, courts, agencies, or others. Limited telephone consultation is part of routine patient care and is undertaken without charge. However, when extensive telephone consultation or other than
routine written correspondence or reports are requested or required, a charge for these services will be applied. If these charges are excluded from coverage by health insurance plan, they will be your responsibility. Every effort will be made to notify you if such charge is likely to occur. However, the exact amount charged cannot always be predicted in advance.

When an appointment is canceled without at least 48 hour prior notification, a $50 fee for the canceled appointment will be charged. If an appointment is missed, considered as a No-Show, a $100 fee for the no-show appointment will be charged. Fees charged for missed appointments or late cancellations must be paid prior to the next appointment. A service charge of 1.5% of the outstanding balance or a minimum of $5 will be added each 30 day billing cycle to all outstanding balances over 60 days past due. A charge of $25.00 will be applied for all checks returned unpaid. If an overdue account is sent to a collection agency, collection fees and expenses will be added to the amount due. A copy of the current applicable fee schedule of Dana Behavioral Health is available upon request. Fees may be modified without notice.

• Acknowledgment and Agreement
I have read the above and affirm that everything in this form that was not clear to me has been explained to my satisfaction. I understand that it is my responsibility to know my insurance benefits. I hereby agree to abide by the policies specified above and to be responsible for all fees and charges for services provided by Dana Behavioral Health to or on behalf of the client named below. This agreement will continue as long as Dana Behavioral Health provides services or until written request that this agreement be terminated is received by Dana Behavioral Health.

• Assignment of Health Insurance Benefits:
This signature below authorizes payment directly to Dana Behavioral Health of benefits under health insurance policy covering the client named below. A photocopy of this form is considered as valid as the original. For Medicare Clients only: The undersigned hereby requests that payment of authorized benefits be made to Dana Behavioral Health on behalf of the client named below. The undersigned authorizes any holder of medical information about the client to release the Health Care Financing Administration and its agents any information needed to determine those benefits payable for related services.

PROVIDER NAME: Dana Behavioral Health    LOCATION: Dana Behavioral Health

Introduction

Telemedicine is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, specialists, and/or subspecialists. Electronically transmitted information may be used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following:

• Patient medical records.
• Live two-way audio and video.
• Output data from medical devices and sound and video files.

The interactive electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional
corruption.

Potential Benefits:

1. Improved access to medical care by enabling a patient to remain in his/her proivder's office (or at a remote site) while the provider obtains test results and consults with healthcare practitioners at distant/other sites.

2. Obtaining the expertise of a distant specialist.

Potential Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

1. Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the
provider and consultant(s).

2. The consulting physician(s) are not able to provide medical treatment to the patient through the use of telemedicine equipment nor
provide for or arrange for any emergency care that I may require.

3. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

4. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

5. A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical judgment
errors.

By signing this form, I understand and agree to the following:

1. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained
during a telemedicine encounter which identifies me will be disclosed to researchers or other entities without my consent.

2. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand
that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any
health benefits to which I am otherwise entitled.

3. I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies
of this information for a reasonable fee.

4. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My
provider has explained the alternative care methods to my satisfaction.

5. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be
located in other areas, including out-of-state.

6. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My
condition may not be cured or improved, and in some cases, may get worse.

Patient Consent To The Use of Telemedicine

• I have read and understand the information provided above regarding telemedicine.
• I hereby consent to and authorize Dana Behavioral Health to use telemedicine in the course of my diagnosis and
treatment.

STATE ISSUED PHOTO ID -Please upload a clear picture or scan of the client's driver's license, state-issued photo ID or passport. *for clients under 18, provide a guardian's photo ID*

INSURANCE CARD FRONT - Please upload a clear picture or scan of the client's front of the insurance card.

INSURANCE CARD BACK - Please upload a clear picture or scan of the client's back of the  insurance card.