New Client Registration PREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 ***ONLINE CLIENT REGISTRATION*** By signing and submitting these online client registration forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. *Yes, I understand and agreeNo, I do not understand or agreeName *Street Address *Apartment, suite, etcCityStateZIP / Postal CodePhone *Email Address *Date of Birth *Social Security NumberResponsible Party / Parent GuardianResponsible Party / Parent Guardian AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeResponsible Party / Parent Guardian PhoneResponsible Party / Parent Guardian Email AddressRELEASE OF INFORMATION: I hereby authorize Preferred Behavioral Health, to release any information about me including the diagnosis and the records of any treatment or examination rendered to me TO my insurance companies or their representatives for the purpose of billing. *Yes, I understand and agreeNo, I do not understand or agreeINSURANCE AGREEMENT: Any benefits of any type under any policy of insurance insuring the client/patient or any other party liable to the client/patient is hereby assigned to Preferred Behavioral Health for any services furnished to me by their providers. If co-payments and/or deductibles are designated by my insurance company or my health plan, I agree to pay them to Preferred Behavioral Health. It is understood that the undersigned and/or the client/patient are primarily responsible for the payment of my bill. Payment is due at the time of service on all office visits unless prior arrangements have been made. It is your responsibility to obtain the proper referral if your insurance requires one for services like under a HMO policy. You will be responsible for any charges that are not covered under the company’s guidelines or charges where a proper referral was not obtained. *Yes, I understand and agreeNo, I do not understand or agreeFINANCIAL AGREEMENT: I agree that in return for the services provided to the client/patient by Preferred Behavioral Health, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Preferred Behavioral Health, for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. *Yes, I understand and agreeNo, I do not understand or agreePOLICY FOR NO-SHOW OR MISSED APPOINTMENTS: It is our policy that if you are to miss 3 appointments within twelve months, our services will be discontinued for noncompliance. No-Show or missed appointments are defined as any scheduled appointment in which the client/patient either 1) does not arrive to an appointment or 2) cancels with less than 48hours notice. For every no-show or missed appointment you will be charged a fee as follows: 1st No-Show is a $25 fee, 2nd and 3rd No-Show is a $35 fee. *Yes, I understand and agreeNo, I do not understand or agreeAPPOINTMENT REMINDERS: I authorize Preferred Behavioral Health to utilize email and text message appointment reminders. I understand that I may revoke this consent at any time by simply notifying the office of Preferred Behavioral Health. *Yes, I understand and agreeNo, I do not understand or agreeELECTRONIC COMMUNICATIONS: I authorize Preferred Behavioral Health to utilize Email as a way to communicate with me. I understand the risks of using email include, but are not limited to: *The email system used could be unencrypted and potentially unsecure, *Email senders can misaddress an email causing the email to be received by unintended recipients, * Email can be intercepted, altered, and forwarded without authorization or detection. I understand that I am responsible for protecting unauthorized access to my email. *Yes, I understand and agreeNo, I do not understand or agreeTELEHEALTH APPOINTMENTS: I understand that I have the option to choose an In-Person office appointment or a telehealth appointment. If I choose to complete a telehealth appointment, I hereby consent to engaging in telehealth and I understand that “telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telehealth also involves the communication of my medical information, both orally and visually, to health care providers. I understand telehealth does not and should not replace a traditional office visit; and therefore, I am proceeding with any telehealth appointments at my own risk and understanding. *Yes, I understand and agreeNo, I do not understand or agreeI HAVE READ, UNDERSTAND AND AGREE WITH THE RELEASE OF INFORMATION, INSURANCE AGREEMENT, NON-COVERED SERVICES, FINANICAL AGREEMENT AND CONSENTS LISTED ON THE FRONT AND BACK OF THIS DOCUMENT. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature Agreement: By signing and submitting these online client forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Preferred Behavioral Health. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature (Type Full Name--Parent Guardian For Minor): *Date *Hours *-120102030405060708091011Minutes *-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMPREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 ***CONSENT FOR TREATMENT*** By signing and submitting these online client registration forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. *Yes, I understand and agreeNo, I do not understand or agreeI have chosen to receive mental health services for myself and/or my child from Preferred Behavioral Health. My decision is voluntary and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law. Nature of Mental Health Services I understand that during the course of treatment I may need to discuss material of any upsetting nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment. Compliance with Treatment Plan I agree to participate in the development of an individualized treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations may be grounds for termination of services, as well as failure to follow my treatment plan in any form. *Yes, I understand and agreeNo, I do not understand or agreeClient Rights: **The right to be treated with dignity and respect by all staff. **The right to be involved in the planning and/or revision of my treatment plan. **The right to know about my treatment progress or lack thereof. **The right to reject the use of any therapeutic technique, and to ask questions at any time about the methods used. **The right to be spoken to in a language that is fully understood. **The right to a clean and safe environment. **The right to end treatment at any time unless court ordered. **The right to confidentiality of clinical records and personal information according to federal and state laws. *Yes, I understand and agreeNo, I do not understand or agreeTelehealth Appointments: I understand that I have the option to choose an In-Person office appointment or a telehealth appointment. If I choose to complete a telehealth appointment, I hereby consent to engaging in telehealth and I understand that “telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand telehealth does not and should not replace a traditional office visit; and therefore, I am proceeding with any telehealth appointment at my own risk and understanding. *Yes, I understand and agreeNo, I do not understand or agreeEmergencies: I understand I may call the office at 618-398-4226 during normal office hours. If not available, I can leave a message and my call will be returned as soon as possible. If I have a life threatening emergency situation, I understand that I should call 911 or go to the nearest emergency room immediately. *Yes, I understand and agreeNo, I do not understand or agreeI HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE STATEMENTS AND GIVE CONSENT FOR TREATMENT. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature Agreement: By signing and submitting these online client forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Preferred Behavioral Health. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature (Type Full Name--Parent Guardian For Minor): *Date *Hours *-120102030405060708091011Minutes *-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMPREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 ***MISSED APPOINTMENT POLICY*** By signing and submitting these online client registration forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. *Yes, I understand and agreeNo, I do not understand or agreeIn an effort to provide all of our clients/patients with quality care in a timely manner, Preferred Behavioral Health has implemented a missed appointment policy. Failure to show up for a scheduled appointment, or notify our office of a cancellation at least 48 hours prior to your appointment time, will result in a $25 missed appointment fee for the first missed appointment and then there will be a $35 fee for any additional missed appointments. Any missed appointment fees will be due at your next scheduled appointment. Our missed appointment policy enables us to better utilize available appointment times for all of our clients who are in need of care. In order to be respectful of the needs of other clients, please be courteous and call our office if you are unable to keep your scheduled appointment. This will allow us to reallocate the appointment time to another client in need of care. Please provide us with a minimum of 48 hours’ notice should you need to cancel or reschedule your appointment. To cancel or reschedule an appointment please call our office and if you do reach our voicemail please leave your full name and the time of your appointment in order to cancel. *Yes, I understand and agreeNo, I do not understand or agreeI HAVE READ AND UNDERSTAND THE MISSED APPOINTMENT POLICY AND THE FEES THAT WILL BE CHARGED FOR EACH OCCURENCE. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature Agreement: By signing and submitting these online client forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Preferred Behavioral Health. *Yes, I understand and agreeNo, I do not understand or agreeElectronic Signature (Type Full Name--Parent Guardian For Minor): *Date *Hours *-120102030405060708091011Minutes *-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMIDChoose FileNo file chosenDelete uploaded fileInsurance Card (front)Choose FileNo file chosenDelete uploaded fileInsurance Card (back)Choose FileNo file chosenDelete uploaded file Submit Online FormPlease do not fill in this field.
