Ewa Ostoja, Ph.D., Licensed Psychologist
149 West Harvard Street, Suite 202, Fort Collins CO 80525 Tel: 970-214-5574 Fax: 970-797-1079
Patient Contact Information Sheet (Child & Adolescent)
Patient’s Name: ______Age ______Date of birth: ______
Street Address: ______
City, State and ZIP Code: ______
Today’s date: ______
Referring person/agency: ______Tel: ______
Is it OK to contact the referring agency to inform them that the patient/family was seen? YesNo
Person Filling form: ______Relationship to patient: ______
ALLERGIES: ______
Please check box if OK to leave a telephone messageat the following numbers. Please note that you and your child may have to fill a separate Release Form to allow such communications (depending on circumstances and the age of the teen).
□Mother’s Name: ______home: ______□Father’s Name: ______home: ______
Mother’s work: ______Father’s work: ______
□Stepmother’s Name ______work: ______□Stepfather’sName ______work: ______
□Adolescent’s Cell: ______
□Mother’s cell (for minors): ______□Father’s cell: (for minors): ______
Step-father’s cell: ______Step-father’s cell: ______
□ Other phone number(s): ______Name: ______
Please check box if it’s OK for Dr. Ostoja to text-message/email the client/family members at:
□ Home Tel : ______□ Mother’s/Father’s Work Tel: ______
□Adolescent’s Cell: ______□email: ______
□Mother’s cell (for minors): ______□Father’s cell: (for minors): ______
□ Other phone number(s): ______Name: ______
email address: □mother: ______□father: ______□other: ______
Other Comments or important information: ______
□I would like Dr. Ostoja to be particularly careful never to disclose any clinical information about me or my child to the following people: ______
Ewa Ostoja, Ph.D., Licensed Psychologist, 149 West Harvard Street, Suite 202, Fort Collins CO 80525
Tel: 970-214-5574 Fax: 970-797-1079
Insurance (please complete even if you plan to file yourself or have a large deductible)
Insured Person’s Name: ______Relationship to patient: ______
Insured Person’s (card holder’s) Birth Date: ______Insured Person’s Employer: ______
Insured Person’s full address (if different from above): ______
Insurance Name: ______ID Number: ______Group #: ______
Insurance contact telephone: ______
Co-pay per visit: ______Maximum visits allowed without pre-authorization: ______
□I give permission to Dr. Ostoja and to her staff allowing contact with my insurance for the purposes of obtaining pre-authorization of benefits, and to enable billing. I understand that Dr. Ostoja may be required to release information regarding diagnosis, dates and duration of sessions, and basic clinical information. I understand that this release will be valid for as long as my child/myself/my family are in treatment with Dr. Ostoja.
______
Signature of Insured or Authorized PersonDate
□I understand that it is my responsibility to contact my insurance and obtain information regarding my benefits, including pre-authorizations, co-payments, and deductibles. If I plan to use in-network benefits, I understand that it is my responsibility to verify that Dr. Ostoja is an in-network provider for my insurance. Dr. Ostoja agrees to bill my insurance directly only of she is an in-network provider. Out-of-network payments must be made to Dr. Ostoja by check or cash at the time of service, and Dr. Ostoja will provide me with a receipt, which I can subsequently submit to my insurance. Because each employer has a unique agreement with an insurance carrier, I understand that it is very difficult for Dr. Ostoja to be familiar with the detailed terms and conditions of each insurance panel. It agree that is my responsibility to verify my benefits with my insurance by calling them directly. I will then communicate any limitations on services coveredto Dr. Ostoja ahead of my sessions. I accept responsibility for resolving directly with my insurance any disputes that may arise from my insurance regarding deductibles, co-payments or changes in my coverage or conditions of my insurance. I understand that Dr. Ostoja will not be calling my insurance to verify or challenge my insurance regarding whether my deductible has been met, or any other issues that are between me and my insurance. Dr. Ostoja’s responsibility rests with billing my insurance for sessions, and providing my insurance with the necessary clinical information to enable payment for services. I understand that I am responsible for payment for any services or sessions that are not covered by my insurance.
______
Signature of Insured or Authorized PersonDate
Please give Dr. Ostoja your insurance card to copy.