Willow Grove | Abington | Harleysville | Bala Cynwyd
DEMOGRAPHIC INFORMATION
Please provide the following information to the best of your ability and as thoroughly as possible.
Date: _____/______/______
Name: ______
Name of Parent/Guardian (if under 18 years):______
Address: ______
______
Date of Birth: _____/______/______Gender: Male Female
Gender Identity:______
Cell: ______May we leave a message? □ Yes □ No
Home: ______May we leave a message? □ Yes □ No
Email: ______
Preferred Language: ______
Marital Status: □ Single □ Married □ Domestic Partner
□ Divorced □ Separated □ Widowed
Employment: □ Full Time □ Student □ On Disability
□ Part- Time □ Unemployment □ Minor/Not Employed
Race: □ Asian □ Pacific Islander □ US Indian/Alaskan
□ Black/African American □ White □ Decline to Specify
Ethnicity: □ Hispanic/Latino □ Not Hispanic/Latino □Decline To Specify
Education: □ Did Not Complete High School/ □ Associates Degrees/Did not College/
Complete Currently in Primary school Currently in College
□High School Graduate □ Bachelor’s Degree or Higher
Smoking Status: □ Everyday Smoker □Former Smoker
□ Occasional Smoker □ Never Smoker
Emergency Contact Information:
Name:______Relation:______
Contact Phone: ______May we leave a message? □ Yes □ No
Family Psychiatric History:
Family Member:______Psychiatric/Alcohol Issue:______
Age of Diagnosis: □ Childhood □ 20-29 □ 40-49 □ 60 and Older
□ Adolescence □ 30-39 □50-59 □ Unknown
Family Member:______Psychiatric/Alcohol Issue:______
Age of Diagnosis: □ Childhood □ 20-29 □ 40-49 □ 60 and Older
□ Adolescence □ 30-39 □50-59 □ Unknown
Family Member:______Psychiatric/Alcohol Issue:______
Age of Diagnosis: □ Childhood □ 20-29 □ 40-49 □ 60 and Older
□ Adolescence □ 30-39 □50-59 □ Unknown
CONSENT FOR TREATMENT
I understand that failure to agree to the release of health care information may affect Collaborative Care’s ability to collect payment through my insurance provider. If this occurs, I understand that I will be responsible for payment at the private pay or out-of- pocket rates ($80.00 - $150.00 depending on provider and services rendered). In addition, if my insurance provider denies payment for any reason, I understand that it is my responsibility to assume the cost of the session(s) at the private or out-of-pocket rates.
Initials:______
Collaborative Care accepts payment in the form of cash, personal check, or all major credit cards (Visa, MasterCard, Discover, and American Express).
Initials:______
I understand that this consent shall remain in effect for the course of my treatment at Collaborative Care. I understand that I may revoke my consent for treatment at any time, by presenting written notice to my clinician and my insurance provider.
Initials:______
I understand that I have the right to cancel my appointment if need be, and that I MUST Provide 24 hours notice in order to do so without fee. If I fail to give 24 hours notice OR do not appear for my appointment, I understand that a $60.00 late cancellation/no-show fee will be charged to my account and will NOT be covered by my insurance provider. This fee can be waived by the clinician if the situation is recognized as an emergency.
Initials:______
I acknowledge that I have read the Collaborative Care Policies and Procedures, and understand that I can request a copy if I desire.
Initials:______
Patient Signature: ______Date:______
Signature of Parent/Guardian (if applicable):______
INSURANCE INFORMATION
Please fill out the following information pertaining to the PRIMARY HOLDER of the insurance policy.
Name:______Date of Birth: ______/______/______
Address:______
Phone Number:______SSN:______
Patient’s Relation to Primary Holder: □ Self □ Spouse □ Child □Other
Employer Name:______WorkNumber:______
I,______, authorize Collaborative Care to Release health care information necessary to process insurance claims to my insurance provider. Any information will be used for purposes of billing, authorizations, or continuity of care only. I understand that shared information will abide by HIPAA regulations.
Patient Signature: ______Date:______
Signature of Parent/Guardian (if applicable):______
EAP INFORMATION (if applicable):
EAP Company:______
EAP Authorization Number:______Number of Approved Visits:______
PRIMARY CARE INFORMATION
Doctor & Practice Name:______
Address:______
Office Phone:______Fax:______
Do you give consent for us to contact your PCP in relation to your treatment: □ Yes □ No
If yes, please chose one of the following communication preferences:
□ Release Records to PCP □Obtain Records from PCP □Maintain Communication with PCP
If yes, please chose which type of information you would like communicated:
□ Evaluation □ Session Notes □ Medication Regimes □ All Records
Patient Signature:______Date:______
Signature of Parent/Guardian (if applicable):______
***FOR CLINICIAN TO COMPLETE***
______, ______/_____/_____, was seen at Collaborative Care on
(Print Patient Name) (Date of Birth)
______for______.
(Date of Appointment) (Reason/Diagnosis)
Summary of Appointment:______
______
The following as determined regarding Medication(s):
□ No Medication Prescribed □ Patient Refused Medication □Medication May be Sought later
□ New Medication(s) Prescribed:______
Further treatment suggestions include:
Lab tests for the following: □ CBC □Thyroid Studies □Chem Panel □ EKG □Other:______
If there are any questions please feel free to contact the office.
______(Provider Signature) (Provider Printed Name) (Provider NPI)
MAGELLAN MEMBER RIGHTS AND RESPONSIBILITIES
Willow Grove Location Abington Location Harleysville Location Bala Cynwyd Location
2300 Computer Ave – Bldg. I, Ste. 51 1369 Old York Road 681 Harleysville Pike 100 Presidential Blvd. – Ste. G1
Willow Grove, PA 19090 Abington, PA 19001 Harleysville, PA 19438 Bala Cynwyd, PA 19004
(P)215-366-5044 | (F)215-366-5948 (P)215-884-1776 | (F)215-884-0171 (P)267-933-5205 | (F)267-932-8660 (P)484-270-8817 | (F)484-278-4634