•   INTEGRAL HEALTH ASSOCIATES

  • New Patient Questionnaire

  • Please complete this form after scheduling an appointment. If you do not have an appointment yet, please call our office at (203) 909-6370 to schedule one before proceeding. 

    This form will take approximately 10-20 minutes to complete. 

    Please have your driver's license or other photo I.D. and your insurance card (or digital copies of these) at hand to complete the form. Thank you. 

  • My appointment is on:*
     - -

  • New Patient Questionnaire

    Please answer the following questions to the best of your ability. Information will be kept confidential. Enter N/A if not applicable.

  • Demographic Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • My Preferred Phone Number is:
  • Is it OK to leave messages?
  • Format: (000) 000-0000.
  • My Alternate Phone Number is:
  • Is it OK to leave messages?

  • Employment Information

  • Are you currently employed?

  • Insurance Information

  • Do you currently have active medical insurance?*

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for Yale Graduate or Professional Students

    If you are a Yale graduate or professional student with Magellan insurance, please contact Magellan before your scheduled appointment to obtain a prior authorization specifically for your visit with {myAppointment}. This must be completed prior to your appointment to prevent your claim from being denied. Magellan will provide you with an authorization number - please keep this number for your records.   

  • Date of Birth of Primary Person Insured
     - -
  • Do you have secondary insurance?

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for Yale Graduate or Professional Students

    If you are a Yale graduate or professional student with Magellan insurance, please contact Magellan before your scheduled appointment to obtain a prior authorization specifically for your visit with {myAppointment}. This must be completed prior to your appointment to prevent your claim from being denied. Magellan will provide you with an authorization number - please keep this number for your records.  

  • Date of Birth of Primary Person Insured
     - -

  • In Case of Emergency Contact

  • Format: (000) 000-0000.

  • Other Healthcare Providers

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Psychiatric History

  • Have you ever...

    (Please indicate Yes or No, and answer any follow-up questions)
  • Seen a therapist in the past?
  • Seen a psychiatrist in the past?
  • Been hospitalized for a mental illness?

  • Have you ever experienced...

    (Please choose the appropriate responses)
  • Panic attacks?
  • Intrusive obsessions that you could not control?
  • Compulsions? (e.g. excessive hand washing, checking locks)
  • Physical abuse?
  • Sexual abuse?
  • Life threatening trauma?
  • Depressed mood nearly every day for at least 2 weeks?
  • Loss of interest in nearly all activities for at least 2 weeks?
  • Thoughts of suicide?
  • Intentional cutting or other ways of harming yourself?
  • Thoughts of harming another person?
  • Days or weeks at a time with very little need for sleep?
  • Out-of-control and markedly excessive spending of money?
  • Continuous period of excessive risk taking?
  • Hearing voices that you were not sure were real?
  • Seeing things that you were not sure were real?
  • Problems with alcohol or street drugs?
  • Problems with prescription painkillers or sedatives?
  • Problems with gambling?
  • An eating disorder?

  • Are you currently experiencing any significant problems with...

  • Sleep?
  • Appetite?
  • Energy?
  • Concentration?

  • Use of Substances

  • Have you ever used the following:

  • Cigarette/nicotine?
  • Alcohol?
  • Marijuana?
  • Cocaine/crack/speed?
  • Heroin/Percocet/Oxycodone/opioids?
  • Ecstasy/LSD/mushrooms?

  • Medical History

  • 0/500

  • Medications

  • 0/500
  • 0/500
  • 0/200

  • Family History of Mental Illness or Substance Abuse

  • 0/500

  • Other

  • 0/250
  • 0/250
  • Is religion an important part of your daily life?
  • Do you attend religious services regularly?
  • 0/500
  • Have you ever been arrested?
  • Do you have any current legal problems?

  • Do you currently have substantial worries about your...

  • Finances?
  • Housing?
  • Job?
  • Health?
  • Relationship(s)?
  • Insurance?
  • 0/500
  • Recent changes in weight?
  • Please indicate if you are currently having problems with any of the following:
  • 0/500
  • 0/500
  • Date
     - -

  • I, {name}, certify that the above information provided is true to the best of my knowledge.

    Signature of patient, parent, or legal guardian (Click on signature line):

    *   

  • Patient Authorization

  • The patient, {name}, is under the age of 18 or is unable to consent to treatment. I,   *   *   , attest that I have legal custody of this individual and/or am legally authorized to initiate and consent to treatment on behalf of this individual.

  • CONSENT FOR TREATMENT

    I consent to participate in behavioral health care services offered and provided by Integral Health Associates (“IHA”). I have read IHA's “Policies, Terms, and Conditions” document and understand and accept the contents therein. Click here to view. This document is included in our online and mailed New Patient Packet, and available on our website (www.integralhealthct.com).

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES (HIPAA)

    I acknowledge that I have read, been shown, or given a copy of the Notice of Privacy Practices of IHA and understand that my protected health information may be used and disclosed for treatment, payment, healthcare operations, and as otherwise permitted by law. Click here to view. This notice is posted in our waiting rooms, included in our online and mailed New Patient Packet, and available on our website (www.integralhealthct.com).

    RELEASE OF INFORMATION

    I authorize IHA to obtain, use, and disclose medical, behavioral health, billing, and related healthcare information as necessary for treatment, payment, healthcare operations, insurance processing, referrals, care coordination, and prescription management, as permitted by applicable law. I understand that I may revoke this authorization in writing except to the extent action has already been taken in reliance upon it.

    E-PRESCRIBING CONSENT

    I authorize providers at IHA to use electronic prescribing systems and access medication history from pharmacies and related healthcare entities for treatment purposes.

    HEALTH INFORMATION EXCHANGE

    I understand that IHA may participate in Connie, the statewide health information exchange, as permitted by law for treatment, payment, healthcare operations, referrals, and care coordination. I understand that I may opt-out and disable access to my health information available through Connie by calling or completing and submitting an Opt-Out form to Connie by mail, fax, or through their website at www.conniect.org. Public health reporting and controlled dangerous substance information, as part of the Connecticut Prescription Monitoring and Reporting System (PMP), will still be available to providers.

    ASSIGNMENT OF INSURANCE BENEFITS & FINANCIAL RESPONSIBILITY

    I authorize IHA to release any and all necessary medical information to my insurance carrier for the purpose of processing claims. When applicable, I authorize IHA to act as my agent in dealing with my insurance carrier to obtain payment and authorize payment of insurance benefits directly to IHA. I accept full responsibility for all charges not paid by insurance, including co-payments, deductibles, coinsurance, missed appointment and late cancellation fees, and other patient-responsible balances. This includes full balances if insurance coverage is denied or terminated. Insurance verification is not a guarantee of payment. If I receive payment from my insurance company for services provided to me by IHA, I agree to submit the payment to IHA. If my account is not paid, I will pay all costs incurred as a result of IHA's collection efforts, including, without limitation, attorney's fees and court costs.

    As a courtesy, IHA may assist me in processing insurance claims; however, I understand IHA accepts no responsibility for any processing procedures, acts, omissions, or neglect. I understand IHA does not guarantee coverage, eligibility, or reimbursement by the insurance company. I understand I am responsible for understanding my insurance benefits and keeping IHA informed of current insurance information. I understand IHA does not submit insurance claims directly for all out of network or self pay services. If I elect to self-pay for services, I understand that IHA will not bill insurance directly, and that I may request a detailed receipt (superbill) to submit directly to my insurance carrier for possible out of network reimbursement, if applicable. I understand that reimbursement is determined solely by the insurance company and is not guaranteed.

    If my bill is not paid in full in a timely manner, I understand IHA reserves the right not to provide future services to me.

    SMS (TEXT) MESSAGING AUTHORIZATION

    I authorize IHA to employ a third party outreach or messaging system to to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of sending SMS (text) messages for appointment reminders, scheduling changes, account notifications, missed appointments, overdue visits, and other reasonable healthcare related communication. I understand that texting may carry privacy risks, that standard messaging or data rates may apply, and that IHA may opt to not communicate by text. I further understand that this consent in no way indicates that IHA will utilize SMS texting as an appropriate or reliable means for me to communicate with them other than by responding to a text I receive with one of the provided response options.

    TELEHEALTH CONSENT

    I consent to telehealth services which includes communication forms such as telephone, cellular phone, and audio-video that occur over information networks. I understand and consent to the following:

    1. Engagement in telehealth is completely voluntary. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. IHA has the right to offer or cease the offering of telehealth for any reason not specifically excluded by law.

    2. Medical documentation of telehealth sessions by IHA will occur based on generally accepted standards, but IHA will not voluntarily record or allow recordings of any part of any telehealth session. Likewise, I agree not to make or allow recordings of any part of any telehealth session.

    3. Despite reasonable efforts by IHA, there are risks and possible consequences from telehealth including, but not limited to, possible disruption of the transmission of my health information by technical failures, possible access and misuse of my health information by unauthorized persons, and the possibility that telehealth services may not be as complete or effective as face-to-face services.

    4. Services provided by IHA through telehealth services are professional services that may or may not be covered by insurance companies. IHA may be able to assist me in filing insurance claims, but ultimately, I am responsible for full payment just as I would be for face-to-face office visits.

    5. I agree to be physically within the state of Connecticut and available for telehealth sessions at the time of my telehealth appointments. This includes having the ringer on for telephone appointments, logging in for video appointments, and being in a quiet, private location with reliable telephone, cellular, wifi, or ethernet connectivity as needed.

    6. Missed appointments will be charged the same as missed face-to-face sessions according to office policy. If I am available and my provider does not contact me within 15 minutes of a scheduled telehealth session, I am free to move on to other activity without being charged for a missed appointment.

    7. If a telehealth session is interrupted due to a technical problem, I agree to immediately make reasonable attempts to reconnect or contact my provider through some other means if available.

    AUTHORIZATION AND SIGNATURE

    By signing below, I acknowledge that I have read and understand this form, have had the opportunity to ask questions, and consent to the policies, authorizations, releases, financial terms, communications, and healthcare services described above.

    Signature of patient, parent or legal guardian (Click on signature line):

    *   *   *   

  • Date
     - -


  • Magellan Health - Members' Rights and Responsibilities Statement


    Members have the right to:

    • Be treated with dignity and respect.
    • Be treated fairly, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
    • Have their treatment and other member information kept confidential. Only where permitted by law may records be released without the member's permission. 
    • Easily access care in a timely fashion.
    • Know about their treatment choices. This is regardless of cost or coverage by their benefit plan.
    • Share in developing their plan of care.
    • Receive information in a language they can understand, and free of charge.
    • Receive a clear explanation of their condition and treatment options.
    • Receive information about Magellan, its providers, programs, services and role in the treatment process.
    • Receive information about clinical guidelines used in providing and managing their care.
    • Ask their provider about their work history and training.
    • Give input on the Members' Rights and Responsibilities policy.
    • Know about advocacy and community groups and prevention services.
    • If asked, Magellan will act on the member's behalf as an advocate.*
    • Freely file a complaint or appeal and to learn how to do so.
    • Know of their rights and responsibilities in the treatment process.
    • Request certain preferences in a provider.
    • Have provider decisions about their care made on the basis of treatment needs.
    • Receive information about Magellan's staff qualifications and any organization Magellan has contracted with to provide services.*
    • Decline participation or withdraw from programs and services.*
    • Know which staff members are responsible for managing their services and from whom to request a change in services.*


    Members have the responsibility to:

    • Treat those giving them care with dignity and respect.
    • Give providers and Magellan information that they need. This is so providers can deliver quality care and Magellan can deliver appropriate services.
    • Ask questions about their care. This is to help them understand their care.
    • Follow the treatment plan. The plan of care is to be agreed upon by the member and provider.
    • Follow the agreed upon medication plan.
    • Tell their provider and primary care physician about medication changes, including medications given to them by others.
    • Keep their appointments. Members should call their provider(s) as soon they know they need to cancel visits.
    • Let their provider know when the treatment plan is not working for them.
    • Let their provider know about problems with paying fees.
    • Report abuse and fraud.
    • Openly report concerns about the quality of care they receive.
    • Let Magellan and their provider know if they decide to withdraw from the program.*

  • * This standard is required for our Condition Care Management (CCM) products.

    My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.

    Signature of patient, parent or legal guardian (Click on signature line):

    *         *   *   

    The signature below shows that I have explained this statement to the patient. I have offered the member a copy of this form. 

    ________________________________
    Provider Signature

  • Date
     - -

  • Please provide a copy of your driver's license or other photo ID and a copy of both sides of your insurance card by uploading them using the button below. 

  • Browse Files
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  • If you're unable to submit them now, please submit them using the online Document Submission Form on our website or via fax. Our preferred fax number is (203) 777-6776 and our alternate fax number is (203) 909-6374. 

    Please be aware that if we do not receive copies of your ID and insurance card at least 7 days prior to your scheduled appointment, your appointment may have to be rescheduled.

  • When you are finished responding to the above questions, please click the submit button below.   

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