PATIENT REGISTRATION – PCS

  1. Patient Registration
  2. Authorization to Release Information
  3. Informed Consent
  4. Couples Consent
  5. Supervised Clinician Consent
  6. Medicare Waiver
  7. Social Media Policy
  8. Intensive Phone Consultations

 

 

PATIENT REGISTRATION

Your information is secure. Our website uses a Secure Sockets Layer (SSL) Encryption Certificate and all data is stored on a HIPAA Compliant server.
Legal Name(required)

         MM/DD/YYYY

Is the patient a minor?
Street Address(required)
Gender
 

Marital Status
 

Preferred Pronoun (if applicable)
 

The best phone number to reach you.

May we have permission to leave you voicemails at this number regarding your appointments at PCS?

The best email to reach you.

May we have permission to email you at this address for correspondence? (We cannot ensure confidentiality when using email correspondence)

Regarding the Use of Email – Email initiated by you and sent to PCS is not confidential. PCS uses a firewall, our computers are password protected, and emails sent from PCS are encrypted when necessary. An email reply you send to PCS is not encrypted. Therefore, we cannot guarantee confidentiality of email communication. If you choose to communicate confidential information with PCS via email, PCS will assume that you have made an informed decision to take the risk that email may be intercepted. Please be aware that email is never an appropriate vehicle for emergency communication. IN ADDITION, these communications may contain material protected by HIPAA and other privacy laws (45 CFR, Parts 160 & 164;42 CFR Part 2)

PCS requires all clients attending the program to have a primary therapist/psychiatrist.

If you do not have an individual therapist enter “not applicable”

If you do not have a couples therapist enter “not applicable”

 

 

Partner Information

Name

         MM/DD/YYYY

Street Address
Gender
 

Marital Status
 

Preferred Pronoun (if applicable)
 

 

 

Other family members who may be relevant to the patient’s therapy at PCS:

         MM/DD/YYYY

         MM/DD/YYYY

         MM/DD/YYYY

         MM/DD/YYYY

Emergency Contact Information

 

 

Please read the following and initial next to each statement to indicate your understanding:

Payment is due at the time of session or when services are rendered

PCS does not accept or process insurance or Medicare, and does not contract with any insurance plans

If I file an insurance claim and the insurance company requests information from PCS, I understand that PCS will not respond to the request and will wait to hear from me (the patient)

PRIVACY PRACTICES ACKNOWLEDGEMENT: I have received the Notice of Privacy Practices (Psychotherapy Patient Services Agreement) and have been provided an opportunity to read and review it

I agree to allow PCS to send me emails regarding events they are sponsoring and surveys pertaining to the Intensive Program (Please note we do not give email addresses or any other personal information to any other organization)

I CONSENT TO CONSULTATION AND/OR TREATMENT OF THE ABOVE MENTIONED PATIENT:

Confirm Full Name(required)