FORM-New Patient Intake CEH New Patient Paperwork Please complete this prior to your initial visit. General Policies & Procedures(Required)Identification – For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card AND a driver’s license OR a valid photo ID at the time of service. You may email these items to info@cehcharlotte.com. Missed Appointments – There will be a $85.00 fee for any missed appointments unless the appointment was canceled or rescheduled at least 24 hours in advance. It is still considered a no show, even if you do not receive a courtesy call. If you incur this $85.00 fee, we cannot refill prescriptions, comply with requests for record transfers, or any other requests until this fee has been paid. Any balance must be paid prior to receiving any services. If you receive three (3) no shows, you are subject to being discharged. Inappropriate Behavior – Patients may be discharged due to disruptive behavior or non-compliance of treatment. Late Appointments – If a patient is 5 minutes late for a follow-up medication management appointment, OR 15 minutes late for an initial appointment, OR 15 minutes late for a follow up appointment with a therapist, the patient must reschedule. Prescription Refills – It is the patient’s responsibility to schedule a follow up appointment BEFORE the prescription runs out to ensure a continued supply of the prescription. If you are prescribed medication, you will be provided an initial prescription and refills to last until the suggested follow up visit. Medication refill requests will be denied if the patient fails to keep follow up appointments. Routine prescription refills will not be provided on the weekends. Disability – As of Monday April 4th, 2022, we will no longer be offering disability services to patients. However, we will continue to offer FMLA services as well as provide records for Disability cases that have been initiated outside of CEH. FMLA services will be subject to a fee which must be paid in advance. Medical Records – Records can be released for a fee of $10.00. This fee must be paid in advance. All medical record requests are subject to be denied per office policy. Record request may take up to 7-10 business days to be completed. Custody – CEH does not participate in any type of custody preceding’s or disputes. CEH has the right to discontinue services for custody related services. Messages – Messages will be returned in the order of which they are received, however if it is an emergency, please call 911. Parents/guardian(s) of children 12 and under must stay on the premises during the entire appointment. Patients 17 and under must be accompanied by a parent or legal guardian to all medication management appointments and other treatment services. I acknowledge the above information and my patient right’s and responsibilities. A copy of the patient rights and the consumer handbook for mental health from NC Department of Health and Human Services is available to me in each CEH office or by request. I agree.Compliance Assurance Notification(Required)All health professionals and office staff continuously undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate uses of Personal Health Information (PHI) in accordance with HIPAA. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to PHI. We want to ensure our patients that our practice will not knowingly contribute in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implanted a Compliance Program that will help prevent any inappropriate use of PHI. Any questions regarding this policy may be directed to the Office Manager. Patient’s Rights & Responsibilities If you are or have been a patient of mental health services, you have the right to ● Access services that are appropriate to your disability, culture, language, gender, and age ● Be treated with respect and with due consideration for your dignity and privacy ● Receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand ● Participate in decisions regarding your health care, including the right to refuse treatment ● Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation ● An individualized treatment plan to ensure quality care and coordination of care. I acknowledge the above information and my patient rights and responsibilities. A copy of the patient rights and the consumer handbook for mental health from NC Department of Health and Human Services is available to me in each CEH office or by request. I agree. Insurance Waiver & Authorization for Payment of Services(Required)I understand that fees paid by my insurance company to CEH for specific services rendered are subject to change. All payments and balances must be paid in order to receive services. Upon receiving final accounting and payment from my insurance company, an additional payment may be required to settle my account with CEH. I understand it is my responsibility to inform the office if my insurance coverage changes at any point in time. I understand that I am financially responsible for any unpaid balance and/or charges not covered/paid by my insurance company. I authorize and request my insurance benefits be paid directly to CEH. This authorization will cover all treatment and services rendered until a written notice of cancellation is received. By typing your name here, you acknowledge agreeing to the above policies and procedures listed above. Patient First Name Patient Last Name Parent or Legal Guardian First Last Refund Policy(Required)There are no refunds to services received for therapy, medication management, processing of forms, or completion of any paperwork, except where CEH is unable to provide services. In such cases, the request for a refund must be reviewed by upper management. Patients that dispute charges for services rendered will be charged a $50 administration fee and will no longer be permitted to pay by credit card or debit card. All future payments must be paid in cash in order to receive services. Patient First Name Patient Last Name Parent or Legal Guardian First Last Insurance Information(Required)**We only bill primary insurance. No secondary insurance will be accepted** Please be advised that CEH does not accept Medicare as primary or secondary insurance. If at anytime your insurance coverage changes to Medicare, you must inform the CEH billing department immediately. Patients who fail to inform the billing department may incur a balance, and/or are subject to discharge. Please acknowledge your Medicare coverage status below, and that you will inform CEH if there are any changes to your coverage. Do you have Medicare? Yes, I have Medicare coverage. No, I am not covered by Medicare Referral Source(Required)How did you hear about us? Check all that apply. Family / Friend Social Media Google School Other Veteran Status(Required)Are you a veteran of the U.S. Armed Forces? If yes, please inform the provider you are seeing. Yes No Patient Name(Required) First Last Date of Birth(Required) Age(Required)We treat patients ages 4 and up.Are you your own legal guardian?(Required) Yes No Guardianship paperwork is required(Required)If you are NOT your own legal guardian, CEH requires that your legal guardian be present at the initial visit, and can provide guardianship paperwork, in order to be seen. I understand and agree to the policy.You primarily think of yourself as:(Required) Male Female Transgender man / transman Transgender woman / transwoman Genderqueer / gender nonconforming Other gender category If you selected "Other gender category Please identify your preferred gender category.What sex was originally listed on your birth certificate?(Required) Male Female Decline to answer Preferred Pronouns Please enter your preferred pronouns here.Marital Status(Required) Phone Number(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation Employer Emergency Contact(Required) First Last Relationship(Required) Emergency Contact Number(Required) Current Symptoms Checklist(Required)Please select any of the symptoms you are currently experiencing. Depressed mood Unable to enjoy activities Sleep pattern disturbances Excessive Energy Avoidance Forgetfulness / Concentration issues Increased risky behavior Racing thoughts Impulsivity Crying spells Excessive guilt Loss of interest Excessive worry Increased sex drive Decreased sex drive Anxiety attacks Fatigue Changes in appetite Paranoia Excessive drinking Substance Abuse Local Pharmacy Name Pharmacy Phone NumberSpecialist Seen(other than CEH) Current Therapist / Counselorif applicable Medication Allergies(Required) Other Allergies Current Medications(Required) including over-the-counter medicinesPrimary Care Physician(Required) Primary Care Physician Contact NumberRelease of Information(Required) I authorize and consent for CEH to exchange/disclose my treatment or my child’s treatment with the primary care physician listed above. I do NOT authorize and consent for CEH to exchange/disclose my treatment or my child’s treatment with the primary care physician listed above. Consent to Treatment for Adults(Required)I do hereby consent to any medical care determined by the CEH medical staff. I consent to any medical care determined by the CEH medical staff.Consent to Emergency Care(Required)I do hereby consent to CEH seeking Medical Care on my behalf in the case of an emergency. I consent to CEH seeking Medical Care on my behalf in the case of an emergency.Consent for Care (select all that apply)As part of my treatment at CEH, I consent to the following options for care: Outpatient Therapy Medication Management Drug Testing Patient Name First Last Consent to Treatment for Minors(Required)I, the parent or legal guardian of the below named patient, do hereby consent to any medical care determined by the CEH medical staff. I consent to any medical care determined by the CEH medical staff.Consent to Emergency Care for Minors(Required)I, the parent or legal guardian of the below named patient, do hereby consent to CEH seeking Medical Care on the patient’s behalf in the case of an emergency. I consent to CEH seeking Medical Care on behalf of the patient in the case of an emergency.Minor Patient's Name First Last Name of Parent or Legal Guardian First Last Urine Screening FAQ & Consent(Required)Why do I need to provide a urine sample? For the health and safety of our patients, CEH collects urine samples to comply with suggested federal guidelines. By monitoring urine samples CEH is able to: * Identify dangerous drug to drug cross-reactivity * Monitor compliance with treatment plans * Understand the actual levels of drugs present in a patient. How often will I have to do this? CEH complies with federal guidelines that require providers to limit patient drug diversion. Patients are subject to random drug testing. How was I chosen? This office will collect samples from ALL patients initially, as well as perform random collections for all patients who are prescribed medications. Who will see the results? Our office staff and lab personnel are authorized to view your results. ** It is CEH policy that we cannot prescribe medication to patients that fail a drug test or have a prior history of substance abuse. We will be able to assist in alternative medications to treat patients. PLEASE NOTE: If you do not consent to drug testing, CEH will not be able to provide any controlled medications. I consent to drug testing. Review & Consent Acknowledgement(Required) I have reviewed this form and agree to the CEH policies above. Name of Patient (or Parent/Legal Guardian)(Required) First Last Date(Required) Please upload a copy of your photo ID, as well as Front and Back of your insurance card below. If you are unable to attach these items here, they must be sent via email to newpatients@cehcharlotte.com prior to your appointment. In the event they are not received before the time of the appointment, you may be rescheduled.Photo IDPlease upload a copy of the FRONT of your photo ID.Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.Insurance Card (FRONT)Please upload a copy of the FRONT of your insurance card.Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.Insurance Card (BACK)Please upload a copy of the BACK of your insurance card.Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB.Insurance CardPlease upload a copy both the FRONT and BACK of your insurance card. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 25 MB, Max. files: 2. Δ
