BJC New Patient Registration

In an effort to provide better care to our patients, we have adopted the following policy changes as well as some reminders. Please carefully read and initial each item and sign where indicated.
1. Our office hours are Monday-Thursday 10am-5pm only. Our office is closed Friday-Sunday. Any calls and/or messages that are of a non-urgent matter will be returned on the next business day.
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2. I agree that I will keep my medication in a safe and secure place away from children.
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3. I will keep the office informed of all my medications (including herbs and vitamins)and/or any medical problems during treatment.
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4. If I am going to have a medical procedure that will cause pain, I will let my practitioner know in advance, so my pain can be treated.
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5. If I miss my appointment, lose my medication, or my medication gets stolen, I understand the prescription will not be refilled.
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6. I understand it is illegal to share, give away or sell my medication. I understand this will result in immediate dismissal.
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7. If you have (2) “No Call No Show” appointments, you will be dismissed from our practice.
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8. If you will be (15+) minutes late, we will have to reschedule your appointment in fairness to our other patients.
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9. Please contact us 7 days prior to you needing a medication refill. It is your responsibility to monitor how much medication you have. Advanced notice is required to make sure you can acquire an appointment.
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10. If you require any letter in regards to your compliance or treatment, we will require at least one weeks notice. No exceptions will be made as we have many clients to accommodate.
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11. If you are on Sublocade or Vivitrol, it is important that you notify our office immediately of any insurance changes, as this can affect the delivery of your injection.
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12. All psychiatric and CDS medications require monthly appointments. There will be NO exceptions. This must be done in person or via lab testing. Urine drug screens will be done to maintain compliance. All drug screens are sent to LabCorp for confirmation.
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13. I understand that I may be called at random to bring my medication bottle(s) into the office for a pill count and agree to do so when requested. Failure to do so or missing medication will result in dismissal.
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14. I agree to follow my practitioner’s recommendation for additional counseling to assist me in my treatment.
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15. I understand there is no fixed length of time for being in treatment.
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16. Dishonesty will not be tolerated as we are here to help you. If you are found to be dishonest regarding your medication, relapse, or anything else pertinent to your care you can be dismissed.
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17. If your insurance company denies payment of services provided to you, you will be responsible for the cost of the office visit. After 60 days of non-payment your account will be sent to collections.
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18. If we feel you require a higher level of care, you will be asked to seek a new provider with advanced expertise.
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19. For females only* I understand if I am pregnant or plan to become pregnant, I will notify my provider to discuss potential side effects of prescribed medications, change them if necessary, and to coordinate care with my OB.
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I thank you for the opportunity to care for you and look forward to our continued professional relationship.

By signing this I am attesting that I understand the updated policies.
Patient Signature
Date:

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Financial and Billing Policy

BJC Total Wellness is committed to providing our patients with the best possible medical care and treatment. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

Insurance

Your insurance is a contract between you, the patient, and the insurance company. We will submit the insurance claims on your behalf. It is the patient’s responsibility to inform the office of any changes to your insurance coverage.

Co-Pays: Co-pays are due at the time of your visit, and they cannot be waived.

Deductibles: Some insurance plans have deductibles. The deductible amount varies based on the insurance plan and/or insurance company. The deductible is the patient’s responsibility and insurance will not cover any benefits until it is reached and paid by the patient.

Uncovered Services: Please be aware that some office visits, labs, testing, medication, and any other medical miscellaneous procedures may not be covered with your insurance coverage. Therefore, it is the patient’s responsibility to understand their insurance benefits and financial responsibilities. Patients are responsible for payment of services rendered and not covered by insurance.

Appointments

We strive to provide the best care in a timely and efficient manner. We will call, text, or email you to remind you of your scheduled appointments. If you need to change or cancel any appointments please do so, as soon as possible. We require at least a 24-hour notice to change or cancel appointments. We will assess a $50.00 fee for any appointment that results in a no call no show. A $25.00 fee if you fail to adequately give 24-hours notice.
I, enter name* certify that I’ve read and understand the financial policy of BJC Total Wellness.
Signature
Date:

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Payment Policy

BJC Total Wellness accepts cash and credit/debit cards (4.99% fee applies).
- We are in-network with: Medicaid, Medicare, AmeriHealth, Blue Cross Blue
  Shield, Tricare, UMR, and Independence.
- Patients are responsible for paying deductibles, co-pays and co-insurance at the
  time of visit.
- If you do not have insurance, you will be required to make payments at every
  visit.
- I understand that the cost of medication and other treatment(s) are not included in this policy—only services provided by BJC Total Wellness.
- I understand the conditions of this Payment Agreement and agree that my
  account must remain current.
- I understand that failure to pay fees on time will violate this Payment Agreement.
- I understand that a violation of this Payment Agreement may result in termination from the program and all services discontinued.
Definitions

Co-payments, Co-insurance, and deductibles. Most insurance plans have cost sharing elements, in which the patients are required to pay portions of their care. If a patient does not pay these amounts, the insurance will not pay for these services. Co-payments, co-insurance and deductibles must be paid at the time of service.

Proof of insurance. All patients must complete our patient information form before seeing the provider. We must obtain a copy of your driver’s license and proof of valid active insurance.

Claims submission. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Claims denied due to the insurance company requesting information from you will be your responsibility.
I, enter name* certify that I’ve read and understand the payment policy of BJC Total Wellness.
Signature
Date:

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Client Rights and Responsibilities Statement

Statement of Client’s Rights
- Clients have the right to be treated with dignity and respect.
- Clients have the right to fair treatment regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
- Clients have the right to have their treatment and other client information kept private. Only where permitted by law, may records be released without client’s permission.
- Clients have the right to share in developing their plan of care.
- Clients have the right to information in a language they can understand.
- Clients have the right to have a clear explanation of their condition and treatment options.
- Clients have the right to information about their therapist, services and their role in the treatment process.
- Clients have the right to ask their therapist about their work history and training.
- Clients have the right to know of their rights and responsibilities in the treatment process.
Statement of Client’s Responsibilities
- Clients have the responsibility to treat those giving them care with dignity and respect.
- Clients have the responsibility to give the therapist the information they need. This is so the therapist can deliver the best possible care.
- Clients have the responsibility to ask questions about their care.
- Clients have the responsibility to follow the treatment plan. The plan of care is to be agreed upon by the client and therapist.
- Clients have the responsibility to follow their prescribed medication regiment.
- Clients have the responsibility to tell their therapist and primary care physician about medication changes, including medications given to them by others.
- Clients have the responsibility to keep their appointments. Clients should call their therapist as soon as possible if they need to cancel their appt.
- Clients have the responsibility to let their therapist know when the treatment plan isn’t working for them.
- Clients have the responsibility to report abuse and fraud.
- Clients have the responsibility to openly report concerns about the quality of care they receive.
My signature below shows that I have been informed of my rights and responsibilities, and that I understand if this information.
Client Signature
Date:

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Consent to Treatment

I acknowledge that I have reviewed, discussed and understand the information about the treatment I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the treatment by the provider named below. I understand that developing a treatment plan with this provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this provider.

I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I may be charged for that appointment.

My signature below shows that I understand and agree with all of the above statements.
Signature of Client:
Date:

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Informed Consent for Laboratory Services

By signing below, you certify that you have read and understand this Patient Informed Consent for Laboratory Services in its entirety, and herby consent to providing specimens of your urine, blood, or other bodily fluids to our office and/or LabCorp for laboratory testing, as appropriate, for the diagnosis and treatment of substance use disorder (SUD) and other conditions as identified by the provider.

During the duration of your care, the practitioner will order certain laboratory tests for
purposes related to your medical care and treatment. We utilize LabCorp for all our
testing. If your insurance utilizes Quest, please inform our staff so we can send your
specimen and/or lab work there. LabCorp or Quest may charge for services rendered,
this is contracted between your insurance company and LabCorp.

Urine Drug Screening (UDS)

We use urine drug screens to evaluate, assess, and manage a patient’s condition. UDS can improve your provider’s ability to screen for and detect substance use, including prescription drug misuse, abuse, and diversion; diagnose and treat substance use disorders; manage chronic care for substance use disorders to support and sustain recovery; and direct therapy with prescription drugs.

You are required to provide samples of your urine for drug testing, including
random testing, to receive treatment at BJC Total Wellness.

If your test results are negative for a prescribed medication or positive for nonprescribed medications or illegal substances, it is considered a positive result and the provider may adjust your treatment plan, including safe discontinuation of your medication, terminate your treatment, or refer you to another treatment provider. Any refusal or inability to provide a urine sample will be treated as a positive result. No medication can be prescribed without a UDS.

Other Laboratory Testing

Early detection and treatment are generally associated with better outcomes. Many
conditions can be detected and treated by your prescribing provider and the tests we
recommend are useful to help improve your health and to ensure that you are free of
conditions commonly observed among individuals with a history of substance use
disorder. It is well documented that individuals with substance use disorders are at an
increased risk for certain medical conditions, including hepatitis, human
immunodeficiency virus (HIV), sexually transmitted infections (STI), hormone
imbalances, liver disease, and kidney disease because of illicit substances, prescribed
medications that have been taken in ways other than directed. All lab results usually
take 3 business days to be available, at that time the office will forward you a copy, and the provider will call you to discuss the results.
I, enter name* certify that I’ve read and understand the financial policy of BJC Total Wellness.
Signature
Date:

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2 digit month, 2 digit day, 4 digit yearDate

Consent for Release of Confidential Information

This consent allows BJC Total Wellness to bill services to your insurance provider, and to communicate with and disclose to one another the following information to any Third- Party Payor (Commercial Insurance Company/Medicaid/Medicare/etc.) related to my care BJC Total Wellness for the purpose of Billing and Collection.

Complete Patient Record for Billing and Collection, including progress reports, chart
notes, urine drug testing results, lab tests, treatment plan, demographics, verification of funding source(s), and billing documentation.

I authorize BJC Total Wellness to disclose to any third-party payor all necessary
information and relevant portions of my patient record for the purpose of receiving
payment for services rendered.

I understand that my alcohol/drug treatment records are protected under the federal
regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42
C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996
(HIPAA), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written
consent unless otherwise provided for in the regulations.

I acknowledge that the information to be released was fully explained to me and that
this consent is given on my own free will and that by signing I have reviewed and
understand the terms of this consent. I understand that I will be provided a copy of this document at my request.
I, enter name*certify that I’ve read and understand the financial policy of BJC Total Wellness.
Signature
Date

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HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides
information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to
update your signature/date. You have the right to restrict how your protected health
information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this
agreement. The HIPAA (Health Insurance Portability and Accountability Act of
1996) law allows for the use of the information for treatment, payment, or
healthcare operations. By signing this form, you consent to our use and disclosure of
your protected healthcare information and potentially anonymous usage in a publication.

You have the right to revoke this consent in writing, signed by you. However, such a
revocation will not be retroactive. By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send a text to you to confirm appointments?
May we leave a message on your answering machine at home or on your cellphone?
Signature
Date

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Authorization to Discuss Protected Health Information
I, enter name authorize BJC Total Wellness to release or discuss information related to my medical condition(including information related to my treatment plan, medical information, and/or billing information) to the following named persons: fields and text.
Check if you do not wish to list anyone
1. Full Name:
Phone Number:
Relationship to Patient:
2. Full Name:
Phone Number:
Relationship to Patient:
3. Full Name:
Phone Number:
Relationship to Patient:
Please be advised that any person not referred to on this list will not be given any
information related to your care, including billing information. You may change,
restrict, or expand this listing at any time.

You are not required to list any name(s) if you do not choose to.
Patient’s Signature
Date

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Enter Patient's Name
Date

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Should be Empty:

Rows	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

Rows	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen

Registration Form

Patient Information

Patient's Primary Address

Patient's Emergency Contact

Preferred Pharmacy Information

Insurance Information

Primary Insurance

Secondary Insurance

PATIENT INTAKE FORM

Social History

PATIENT INTAKE FORM

PATIENT HEALTH QUESTIONNAIRE-9 ( P H Q - 9 )

GAD-7 Anxiety Screening

Authorization to Discuss Protected Health Information