Semper Healthcare Services Inc. Opioid Medication Management/Mental Health Solutions 15080 East Beltwood Parkway. Suite #110. Addison TX. 75001 Small steps, big changes Office: 1-469-466-8595 |email: info@semperhs.com I web: semperhs.com

*/ understand that by giving this address, statements and necessary forms will be mailed to the address provided. *

Unless otherwise specified below, by providing phone numbers and emails you are giving permission for TMS Institute of America to leave voice mails and contact you via email. For additional information on email communication and privacy, please see our privacy policy.

Cell: (Default) Email Address:

Optional: Do Not Leave Voicemails on the following phone number(s):

Please use my email address for:

For Clinic Updates and Newsletters

Appointment reminders may be provided by our Electronic Medical Records (EMR) system. When your appointment is scheduled, the computerized system can send out a reminder 24 to 48 hours in advance. By completing this section, you acknowledge that information through email/text/voice mail is not necessarily secure and we cannot guarantee that someone else will not access information regarding your appointment through these means. You may leave appointment and follow-up reminders.

If you prefer to receive reminders, please check the box that applies:

Emergency Contact Information: Name:

In the event of an emergency may we contact this person regarding your care here?YesNo

Additional Contact Information: (Your insurance will require this information for prior authorization)

In order to obtain prior authorization, we may need to contact these providers regarding your care. Do you authorize us to contact the above indicated providers?YesNo

Intake form Page 2 Financial Responsibility Agreement: TMS Institute of America reserves the right to charge for services rendered by any practitioner or provider employed by Acuity TMS of Plano. Please see the different sections below toindicate how

payment will be collected, and services will be billed. For any questions regarding this section, please contact our Billing Department.

Payments and Billing: *If you are 18 years of age or older, unless other signatures are provided, statements and financial responsibility will default to you.

Billing for services rendered is handled in-house by our Billing Department. Client Statements are typically sent out within one month following treatment to the address provided in the client information section above. For privacy reasons, we do not fax or email statements unless specifically requested as a one-time courtesy. We expect co-pays and any co-insurance or deductible to be paid at the time of service or within the billing cycle after your Explanation of Benefits (EOB) is received when not paid at the time of service. To maintain a manageable client balance, the front office personnel will require payment of your co-insurance, copay, and/or deductible at the time of service. We accept payment via credit card, cash, or health savings card (HSA) at each location. We do not accept credit card payments over the phone and do not keep credit or debit card information on file within our billing system without the expressed written consent of the patient, and only in rare cases when necessary. Please do not provide any staff member of Semper Healthcare Services your credit or debit card information. Credit card information should only be provided to our Billing Dept. when needed.

By signing this form, you acknowledge that your insurance coverage, notification of any pre-authorization requirements, and terms of coverage are ultimately your responsibility. We make every effort to obtain prior authorization of TMS therapy services from your insurance provider; however, this prior authorization is not a guarantee of payment from your insurance. It is also your responsibility to notify us of any insurance changes that occur during the course of treatment. Changes in insurance providers often require a new prior authorization to be obtained.

Signature of Patient If the Insurance Holder/Subscriber is different than that of the Client/Patient receiving services, please provide the information here:

By signing this form, you acknowledge that by scheduling an appointment, we reserve time specifically for you. This time is set aside and prevents others from scheduling during your reservation. We request a minimum of 24 hours' notice for any cancellations or reschedules. Because of the time set aside, if proper notice is not given for rescheduling or cancellation, a cancellation fee of $60.00 will be applied to your account. Additionally, insurance does not cover missed appointments. Please be aware that failure to receive a reminder does not waive this cancellation fee. You are still responsible to remember your appointment date(s) and time(s We allow a maximum of two (2) missed appointments during the course of TMS therapy per episode without applying a cancellation fee providing the appointment was canceled within a reasonable amount of time. These two (2) missed/canceled appointments are to be used for unanticipated situations or circumstances.

Special Circumstances: We make every effort possible to respect the wishes of our clients. However, Semper Healthcare Services and its affiliates is not responsible for maintaining financial arrangements made between separated or divorced parents or couples under any circumstances. If there is a financial agreement between such parties, we respect your privacy, and require that you manage those arrangements. For financial responsibility in these types of cases, the person whose signature is on file on the registration paperwork is deemed the party responsible for payment.

By signing this document, you acknowledge that unpaid balances of 60 days past due status may be subject to be submitted for collections. If balances are not paid, we reserve the right to utilize collection agency services. We make every effort to work with clients and provide ample time and opportunity for payment. Payments are accepted in person or by mail. Additionally, payment plans are offered upon request.

By signing this document, you agree to the following statements: I agree to participate in treatment and understand that a positive outcome cannot be guaranteed. I understand that positive outcomes are based on my compliance with treatments. I also understand that there are some instances that TMS therapy could worsen my symptoms in certain circumstances, and participation does not guarantee that my symptoms or concerns will be resolved. Acuity TMS of Plano assumes that when referred by a physician with a diagnosis of Major Depressive Disorder, that this diagnosis is correct in the Client's/Patients requested medical records. When not able to obtain certain medical records, Semper Healthcare Services relies upon the information you provide to us and assumes this information to be accurate to the best of your knowledge. The information you provide is used to obtain prior authorization of services from your insurance.

I have read and agreed to the Privacy Notice (HIPAA Statement) provided to me. I understand that I can obtain a printed copy from the staff and can ask for clarification on any policies stated in it. understand the policies outlined above.

Do you have a diagnosis of major depression?

Are you currently taking antidepressant medications: YESNO Please list your current and previous medications (fill in start/stop dates to the best of your knowledge as this information is required for prior authorization from most insurances):

(side effects, stopped working, etc

Are you currently taking or have you ever taken any medication for a seizure disorder:

In the past 6 months, have you used alcohol (ETOH), illicit drugs, or abused benzodiazepines (Klonopin, Xanax, Ativan, etc: YES

If so, do you drink ETOH on a daily or weekly basis? YES / NO How much per:day If you use illicit drugs, which ones: Marijuana / Opiates / Cocaine / Hallucinogens / Other If you abuse

TMS Therapy Insurance Authorization

For insurance pre-authorization insurance companies require the following (this is not a complete list of requirements, but most minimum requirements for TMS therapy):

A confirmed diagnosis of Major Depressive Disorder Prior trials of antidepressant medications with little or no benefit from depression symptoms OR medication discontinuation due to side effects (each insurance requires a specific number of antidepressant trials - for example, Medicare requires a minimum of two (2) antidepressants with little or no benefit or inability to continue to medication due to side effects.No history of seizures A history of psychotherapy with little or no benefit (physician, therapist, counselor, outpatient mental health visits, etc No TMS Therapy contraindications Insurance requires TMS Institute of America to have medical record documentation of all of the above, including other qualifying information, on order to obtain prior authorization for TMS Therapy services. Upon receipt of Client / Patient medical records, Acuity TMS of Plano will submit a prior authorization to Clients / Patients insurance provider per Client / Patient authorization. Do you provide permission for Acuity TMS of Plano to submit a prior authorization request to your insurance provider for TMS therapy (transcranial magnetic stimulation) services and/or for services to be provided to you by one of our physicians or healthcare providers. Please circle: YES / NO

I have read or have been made aware of the following: HIPPA Notice and Patient Privacy Acts TMS Therapy Contraindications TMS Therapy Hearing Protection Waiver Indications for and any side effects of TMS Therapy, including an explanation of TMS Therapy for the treatment of major depression or other diagnosis that I may be receiving TMS Therapy for. I have had all of my questions and/or concerns