New and Improved New Patient Packet

Park Valley Behavioral Health Care

The Maxwell Centre, Suite 500

32 20th Street

Wheeling, WV 26003

Phone: (304) 218 - 2023 Fax: (304) 907-4259

Please note our accessible parking and entrance

on the Market Street side of the building.

New Patient Packet

Thank you very much for your interest in our services!

Feel free to ask for assistance with anything you do not understand.

Services:

General Psychiatry and Psychotherapy

Child and Adolescent Mental Health Services

Perinatal (Pregnancy & Postpartum) Mental Health Services

Certified medication management and therapy services

Medication Assisted Treatment (MAT) for Opioid Addiction

Our MAT Program requires participation in therapy and 12 Step Meetings

Note:
- Our prescribers do not treat for pain.
- We do not prescribe controlled substances at first visit.
- Past and present pharmacy records are reviewed.
- We are not accepting new patients seeking legal assistance, disability, FMLA or workers' compensation.
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*

INSURANCE AUTHORIZATION AND RELEASE:

I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered to me or my dependents during the period of such care to a third party payers (insurance) and/or other health practitioners as requested.

I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that the patient responsibility is due at the time of service. Any co-pay and past due balance must be paid at the time of service.

By signing this form, I accept and agree to these polices. My signature indicates my consent to treatment for myself or my dependent. I give consent for the doctor to request my medication prescription history from pharmacies for continuity of care.
Signature*

Clear
Date*

MonthDayYear
Date
Primary Insurance - Insurance information is required to schedule an appointment

(If no insurance, type "self pay")
Insurance Company:*
ID:*
Group #:
Individual yearly deductible amount:
Dollar amount - please call the customer service number on your insurance card for this information
Insurance effective date:

MonthDayYear
Date
Responsible Party Information (Person who holds the insurance)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Relationship to Patient
Social Security Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are able to do so, please upload your insurance card
Front of Insurance Card
Back of Insurance Card
Secondary or Additional Insurance

Leave blank if no additional insurance
Insurance Company:
ID:
Group #:
Individual yearly deductible amount:
Dollar amount - please call the customer service number on your insurance card for this information
Insurance effective date

MonthDayYear
Date
Responsible Party Information (Person who holds the insurance)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Relationship to Patient
Social Security Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are able to do so, please upload your insurance card
Front of Insurance Card
Back of Insurance Card
Signature*

Clear
Date*

MonthDayYear
Date

Office Policies

Thank you for selecting use as your provider for psychiatric services. We look forward to working with you in helping you attain your goals.

Please read the following information and sign below to indicate your understanding and agreement to abide by our policies.

CONFIDENTIALITY

Your privacy is an important component of your treatment. No one other than office personnel will have access to your file, without your consent, except in the following situations:

1) Future harm being threatened by client to self or someone else will be reported.

2) Criminal activity on our premises or targeting our personnel will be reported.

3) Child or disabled adult neglect or abuse must by law be reported to Protective Services.

4) Court ordered or subpoenas of records may occur.

Should any of the above conditions occur that necessitate breach of your confidentiality, you will be informed immediately.

EMERGENCIES

Should a crisis arise during office hours, please call 304-218-2023. The office staff will assist you in reaching your provider or refer you to the appropriate facilities. When the office is closed, an answering service is utilized, which can be reached at 304-218-2023.

Please use the answering service for EMERGENCIES only. The answering service will not take messages regarding scheduling or medication refills.

SCHEDULING

We do our best to schedule you promptly. If an unavoidable conflict arises, please call the office during business hours as soon as possible. Please see our No Show Policy below for more information about changing and/or missing appointments. Our office hours are Monday to Thursday, 9:00am to 4:00pm, and Friday 9:00am to 3:00pm, except from 12:00pm to 1:00pm daily. We are closed for major holidays.

NO SHOW POLICY

New patient evaluation
If you cancel your initial appointment at least 24 business hours before the appointment date and time, you can re-schedule after six months. If you late cancel or no show your initial appointment, you must re-apply after one year.

Established patients
We understand that circumstances arise that do not allow you to keep your appointments, but please remember to be courteous by calling the office staff at 304-218-2023 at least 24 business hours prior to your appointment time to cancel if you cannot make it.

Our business hours are Mon-Thurs 9am-12pm and 1pm-4pm and Fri 9am-12pm and 1pm-3pm. Our answering service is for handling urgent medical issues only and is not authorized to take cancellations. At this time, we do not have an encrypted email service.

This practice is operating with a waiting list of people in need who could greatly benefit from your providing at least 24 business hours notice to cancel your appointment.

First and second missed appointments: A $45 fee may be applied to your account that should be paid in full prior to being seen for an appointment again.

Third missed appointment: At this point, since you have not been consistently active in your treatment, we have not been able to meet your needs, and you may be discharged. You will be notified by mail.

Most of our clients at Park Valley will not miss an appointment, so this will not be an issue. If you call and cancel at a time that gives the office notice, we can fill your spot with a client that may have been denied an appointment. If you have questions, please talk to any of the staff at Park Valley.

We appreciate that you have chosen us as your provider(s).

FORMS

There will be a $10.00-$25.00 fee for filling out forms, if your provider agrees to complete your form(s). This payment is your responsibility.

PAYMENT

You are financially responsible for treatment fees. Payments for co-pays are required at the time of service. If you have a balance after the insurance pays, you will be billed and expected to pay the balance within 30 days. Please let us know if you need a payment plan, and all efforts will be made to reach a reasonable agreement.
Signature*

Clear
Date*

MonthDayYear
Date

Park Valley Behavioral Health Care

Payment Policy

Effective Date: 11/01/2024

Purpose: To outline our payment policy, including procedures for handling account balances over $150.00.

1. Payment Responsibility
- Insurance Coverage: As a courtesy, we will bill your insurance company directly. However, it is your responsibility to understand your insurance benefits and to pay any co-payments, co-insurance, deductibles, no-show fees, or other charges not covered by your insurance.
- Account Balances: After your insurance has processed your claim, any remaining balance becomes your responsibility. This includes balances resulting from services not covered by your insurance or if your insurance denies a claim.
- Due Date: Payment is due within 30 days of the statement date. If you are unable to pay the full amount, please contact our billing office immediately to discuss payment options.
2. Balances Over $150.00
- Notification: If your account balance exceeds $150.00, you will be expected to pay the balance in full. If payment is not received, appointments may be canceled until payment is submitted. This balance may not include pending charges that have not yet been finalized with your insurance provider.
3. Payment Options
- Methods of Payment: We accept the following forms of payment:
- Credit/Debit Cards (Visa, MasterCard, American Express, Discover)
- Personal Checks
- Money Orders
- Cash
- Online Payments: If you receive email statements, you may be eligible to pay your balance in full online. See your statement header for instructions.
4. Payment Plans
- Eligibility: If you are unable to pay your balance in full, we offer payment plans for balances over $150.00. Payment plans must be arranged before the due date of the outstanding balance.
Terms and Conditions:
- Initial Payment: A minimum initial payment of 25% of the total balance is required to set up a payment plan.
- Monthly Payments: The remaining balance can be divided into equal monthly payments, typically over a period of 6 months.
- Automatic Payments: To ensure timely payments, we strongly encourage setting up automatic monthly payments through a credit or debit card.
- Agreement: A payment plan agreement will be documented and signed by both the patient and a representative of our office. The agreement will outline the payment schedule, amounts, and due dates.
- Late Payments: If a payment is missed or late, the payment plan may be voided, and the full balance may become due immediately.
5. Outstanding Balances and Collections
- Account in Good Standing: To continue receiving medical care, your account must be in good standing. This means either having a balance below $150.00, being up to date on a payment plan, or having paid the balance in full.
- Collections: Accounts with balances over $150.00 that remain unpaid for more than 90 days may be turned over to a collection agency. Additional fees may apply, and your credit rating could be affected.
6. Financial Hardship
- Assistance Programs: If you are experiencing financial hardship, please contact our billing office to discuss possible assistance options. We are committed to working with you to find a solution.
7. Contact Information
- If you have any questions regarding your account, or if you need to set up a payment plan, please contact our billing office at:
  - Phone: 304-218-2023
  - Office Hours: 9:00 am to 4:00 pm
Acknowledgment:

By receiving services at Park Valley Behavioral Health Plan, you acknowledge that you have read and understand this payment policy and agree to abide by its terms.
Signature*

Clear
Date*

MonthDayYear
Date
This policy is designed to ensure that our office can continue providing high-quality care to all patients. We appreciate your cooperation and understanding.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*
I Name*, have received a copy of this office's Notice of Privacy Practices.
Signature*

Clear
Child's Signature (If 12 years or older)

Clear
Date*

MonthDayYear
Date
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care and treatment.

I understand that this information serves as:
- A basis for planning my care and treatment.
- A means of communication among the many healthcare professionals who contribute to my care.
- A source of information for applying my diagnosis and surgical information to my bill.
- A means by which a third-party payer can verify the services billed were actually provided.
- A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.
I understand that I have the right:
- To object to the use of my health information for directory purposes
- To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations - and that the organization is not required to agree to the restrictions requested.
- To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
Signature

Clear
Date*

MonthDayYear
Date

Park Valley Behavioral Health Care No Show Policy
New Patient Evaluation

Please ensure you schedule your evaluation appointment at a good time for you, they can not be rescheduled. If you cancel your initial appointment at least 24 hours before the appointment date and time, you are able to re-schedule your evaluation after six months. If you late cancel (within 24 hours of your appointment) or no show your initial appointment, you must re-apply after one year.

Established patients

We understand that circumstances arise that do not allow you to keep your appointments, but please remember to be courteous by calling the office staff at (304) 218-2023 at least 24 business hours prior to your appointment time to cancel if you cannot make it. Our business hours are Monday-Thursday 9am-12pm and 1pm-5pm and Friday 9am-12pm and 1pm-4pm. Our answering service is not authorized to take cancellations.

This practice is operating with a waiting list of people in need who could greatly benefit from you providing 24 hours notice to cancel your appointment. Same day cancellations are counted as missed appointments.

First and second missed appointments: A $45.00 no show fee may be applied to your account that you must pay in full prior to being seen for an appointment again.

Third missed appointment: At this point, since you have not been consistently active in your treatment, we have not been able to meet your needs, and you may be referred elsewhere for treatment. Other options will be provided to you with names and phone numbers of other providers.

If you have questions, please talk to any of the staff at Park Valley. We appreciate that you have chosen us as your provider(s).

Note: Our texting system is automated. It is intended for appointment reminders only. We do not respond to text messages. In order to cancel an appointment, you must CALL the office during business hours at least 24 business hours before your scheduled appointment time.

Your signature below indicates that you have read and understand the terms and conditions of the No Show Policy.

*Please note that patients enrolled in Park Valley's Suboxone Treatment Program should refer to their treatment contract for program specific policy regarding missed appointments.
Signature

Clear
Date*

MonthDayYear
Date

	Yes	No
... you felt so good or so hyper that other people that you were not your normal self or you were so hyper that you got into trouble?
... you were so irritable that you shouted at people or started fights or arguments?
... you felt much more self-confident than usual?
... you got much less sleep than usual and found you didn't really miss it?
... you were much more talkative or spoke faster than usual?
... thoughts raced through your head or you couldn't slow your mind down?
... you were easily distracted by things around you that you had trouble concentrating or staying on track?
... you had much more energy than usual?
… you were much more active or did many more things than usual?
… you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
… you were much more interested in sex than usual?
… you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
… spending money got you or your family in trouble?

Child's Medical History

Developmental Questions:

Medical History

Primary Insurance - Insurance information is required to schedule an appointment

Secondary or Additional Insurance

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Park Valley Behavioral Health Care No Show Policy

Edinburgh Postnatal Depression Scale (EPDS)

Mood Disorder Questionnaire (MDQ)