Adult New Patient Registration Form

New Patient Registration

Please fill in the form below
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Can we text this number ?*

YesNo
Primary E-mail*
Was this evaluation recommended by another professional:*

YesNo
By whom?*
This form was completed by: *
First Name, Last Name, Relationship to Patient
How did you hear about us?*

Emergency Contact

Please list someone other than yourself
Emergency Contact:*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to the patient*
Emergency Contact:*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to the patient*

Family History
Please list the name (s) of other people living with the patient. Include relationship to patient, age and sex*
Example: Kristin, sister, 28, F
What languages are spoken in the home?
Does anyone in your immediate or extended family have any language or learning difficulties?*

YesNo
Please describe:
Does anyone in your immediate or extended family have any medical concerns: (mental illness, cognitive disability, hearing problems, seizure disorders etc.)*

YesNo
Please describe:
Are there any family circumstances you feel we should know about? (new baby, divorce, separation, recent death in the family)*

YesNo
Please describe:

	Normal	Hearing Loss	Further Testing
Current

Education and Work History
What is your highest level of education completed?

Middle SchoolHigh SchoolHome SchoolSome CollegeAssociates DegreeGraduated CollegeMasters DegreeDoctorate Degree
What is your current Job?
Is there any other information about your education or work you would like us to know?
What are your goals for therapy?*

Responsible Party

(Parent, Legal Guardian, or self)
Is the responsible party's address the same as the patients ?*

YesNo
Name*

First NameLast Name
Relationship to Patient *
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com

Credit Card Authorization
By completing this form I understand that if I have an outstanding balance of more than 60 days, I will be enrolled in an automatic withdrawal payment plan of 40% of my outstanding balance until I carry a zero balance.*

I acknowledge
Please charge my credit card in the amount of my monthly balance automatically*

YesNoI would like to learn about a payment plan
It is our policy to keep a credit card on file for all patients. Please bring a credit card to your appointment as you will be asked to complete an authorization form.

Financial Agreement and Policies
Will you be using health insurance?

YesNo

Primary Care Physician
Primary Care Physician Name*
Phone number*

Area CodePhone Number
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I understand that I am participating in a cash for services plan and that my insurance will NOT be billed.*

I acknowledge
I understand that statements will ONLY be sent to the responsible party.*

I acknowledge
I understand the cash fee schedule as follows: Evaluation $400; Treatment (30 minutes)$130.*

I acknowledge
I understand that a $50 cancellation fee may be billed to my account if I do not contact Start Bright with at least 2 hours notice of a cancellation.*

I acknowledge
I understand that I may be discharged from Start Bright if more than 40% of scheduled sessions within a 60 day period are not attended.*

I acknowledge
I understand that payment plans are available at my request.*

I acknowledge
By completing this form I understand that if I have an outstanding balance of more than 60 days, I will be enrolled in an automatic withdrawal payment plan of 40% of my outstanding balance until the balance falls below $100 at which time the remaining balance will be ran in full.*

I acknowledge

Insurance Information
Name of Insurance company*
If you do not see your insurance company please speak with your therapist.
Contract Number*
Group Number*
Policy Holder*

PrefixFirst NameMiddle NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Employer*
Do you have a secondary insurance?*

YesNo

Name of Insurance
If you do not see your insurance company please speak with your therapist.
Contract Number*
Group Number*
Policy Holder*

PrefixFirst NameMiddle NameLast Name
Relationship to patient*
Employer*

HIPPA Notices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective April 14, 2003, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use, and disclosure of your health records:

We will attempt in good faith to obtain your signed acknowledgement that you received this notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.

Treatment: We will use your health information to make decisions about the provision, coordination, or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.

There are certain circumstances under which we may use or disclose your health information without first obtaining your acknowledgement or authorization. Those circumstances generally involve public health and oversight activities, law- enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases, or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death.
(1) We are required by law to maintain the privacy of the protected health information in your records and to provide you with this notice of our legal duties and privacy practices with respect to that information.
(2) We are required to abide by the terms of this notice currently in effect.
(3) We reserve the right to change the terms of this notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in this notice will be prominently displayed and available at our office.
There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this notice of privacy practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment, or health care operations requires you to sign an authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your acknowledgement or authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.
Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification, and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

Operations: Your health records may be used in our business planning and development operations including improvements in our methods of operation and general administrative functions. We may also use the information in our overall compliance planning healthcare review

This is for your records. You do not need to bring this to your appointment.
Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental health treatment, drug and alcohol abuse, HIV/AIDS, or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government’s web site, http://www.hhs.gov/ocr/hipaa.

You have certain rights regarding your health record information, as follows:

(1) You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction.
(2) You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled.
(3) You have the right to inspect, copy, and request amendments to your health records. Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.
(4) All requests for inspection, copying and/or amending information in your health records, and all requests related to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address. We will respond to your request in a timely fashion. (5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your health information except for disclosures required for treatment, payment and healthcare operations, disclosures that require an authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period. (6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice and to take one home with you if you wish.

All questions concerning this Notice or requests made pursuant to it should be addressed to: PRIVACY OFFICER, Start Bright, 50 Kirts Blvd., Ste. G Troy, MI 48084

HIPAA Notice of privacy practices:2019
I acknowledge I have received a copy of my HIPPA rights.
I understand that if I would like a hard copy of my HIPAA rights, I can ask my therapist at any appointment.

Treatment Consent and Notification of Rights Form
I give my consent for speech therapy-evaluation and treatment.*

I consent
I understand that my consent may be withdrawn by me in writing at any time. If my consent is not withdrawn, it shall automatically terminate one year from the date I have provided consent.

To the best of my ability, the information I have supplied is complete and truthful.*
Type Name
E-Signature

Clear
Date

MonthDayYear
Date
By accepting and/or scheduling any appointment with Start Bright, you are agreeing to abide by the policies and procedures contained in this packet.

Location Information

50 Kirts Blvd SuiteG

Troy, Michigan

48084
Should be Empty:

New Patient Registration

Emergency Contact

Family History

Medical History

Education and Work History

Responsible Party

Credit Card Authorization

Financial Agreement and Policies

Primary Care Physician

Insurance Information

HIPPA Notices

Treatment Consent and Notification of Rights Form