Child Registration - Psychologists | Toms River, Manahawkin, Freehold, NJ

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Which office is your appointment in?*
- Toms River
- Freehold
PATIENT REGISTRATION
Please complete all information
Patient Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Best Phone # to Reach You*
Date of Birth*
Sex*
- Male
- Female
Social Security #
Marital Status*
- Married
- Single
- Divorced
- Widowed
- Engaged
Full Name of Referring or Primary Care Physician
First Last
Dr.'s Phone #
Dr.'s Address
Street Address City State ZIP Code
Emergency Contact Person
First Last
Emergency Contact Phone #
Employer
School
INSURANCE INFORMATION
If not known, please enter N/A
Insurance Name*
Phone*
Address*
Street Address City State ZIP Code
ID #*
Group #*
Insured Full Name*
Insured Date of Birth*
Insured Relationship to Patient*
Insured Employer*
SECONDARY INSURANCE (Medicare patients only)
Insurance Name
Phone
Address
Street Address City State ZIP Code
ID #
MOTOR VEHICLE INSURANCE (Motor Vehicle patients only)
Motor Vehicle Insurance Name
Address
Street Address City State ZIP Code
Adjuster Name
Phone
Claim #
RELEASE FOR PROFESSIONAL INFORMATION
I hereby authorize Pathways Neuropsychology Associates to obtain or release protected information pertaining to my treatment. This information should only be released to the following:
PCP/Physicians
Attorney
Other
If patient is a minor, parent or guardian are required to sign this release. If minor is 14 years or older, their signature is also required.
Signature*
Relationship
APPOINTMENT CANCELLATION POLICY
We reserve the right to charge a reasonable and customary fee, $50.00 for missed appointments or services scheduled for you if you...
1. Fail to call 24 hours in advance to cancel or reschedule.
2. Fail to attend the appointment without giving 24 hours notice.
3. Arrive too late for the doctor to see you at your scheduled time.

This is to confirm that I have been made aware of the above policy.
Signature*
Date*

CONSENT FOR PURPOSES OF TREATMENT & HEALTHCARE OPERATIONS
I consent to the use or disclosure of my protected health information by Pathways Neuropsychology Associates for the purpose of diagnosing or providing treatment to me and in obtaining payment for my health care bills. I understand that diagnosis or treatment of me by Pathways Neuropsychology Associates may be conditioned upon my consent and evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Pathways Neuropsychology Associates is not required to agree to a restriction that I request. However, if Pathways Neuropsychology Associates agrees to a retraction that I request, the restriction is binding on Pathways Neuropsychology Associates. I have the right to revoke this consent, in writing at any time, except to the extent that Pathways Neuropsychology Associates has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by Pathways Neuropsychology Associates, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have the right to review Pathways Neuropsychology Associates Notice of Privacy Practices prior to signing this document and this has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills, or in the professional health care operations of Pathways Neuropsychology Associates. this Notice also describes my rights and Pathways Neuropsychology Associates duties with my protected health information.

Pathways Neuropsychology Associates reserves the right to change the Privacy Practices that are described. I may obtain a revised copy by calling the office, and I have the right to revoke this consent at any time.

Our office will make every attempt to collect payment from your insurance company. Please remember that payment of your bills is ultimately your responsibility. Your deductible and co-payment amounts are determined by the insurance coverage you and your employer selected. You are required to pay these deductibles and co-payments at the time of service. If you are in dispute of these amounts, it is your responsibility to address the problem with your insurance company. All individual providers are billed under Tax ID #81-3236538. It is your responsibility to use this information to confirm that your provider is “in-network.” A “covered service” does not necessarily mean that it will be a paid service. As a result, you may be financially responsible for all or part of the services provided by our office.

I have read the information listed above and understand that I am financially responsible for all services not paid by my insurance company.
Patient Name*
First Last
Date*
Signature*

PATIENT HIPAA CONSENT
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

1. Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
2. Obtaining payment from third party payers (e.g. my insurance company);
3. The day-to-day healthcare operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Patient Name*
First Last
Date*
Signature*
Relationship to Patient

MEMBERS' RIGHTS & RESPONSIBILITIES STATEMENT
MEMBERS' RIGHTS

• Members have the right to be treated with dignity and respect.

• Members have the right to fair treatment; regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.

• Members have the right to have their treatment and other member information kept private. Only where permitted by law, may records be released without member permission.

• Members have the right to easily access timely care in a timely fashion.

• Members have the right to know about their treatment choices. This is regardless of cost or coverage by the member’s benefit plan.

• Members have the right to share in developing their plan of care.

• Members have the right to information about Magellan, its practitioners, services and role in treatment process.

• Members have the right to information about clinical guidelines used in providing and managing their care.

• Members have the right to ask their provide about their work history and training.

• Members have the right to give input on the Members’ Rights and Responsibilities policy.

• Members have the right to know about advocacy and community groups and prevention services.

• Members have the right to freely file a complaint or appeal and to learn how to do so.

• Members have the right to know of their rights and responsibilities in the treatment process.

• Members have the right to receive services that will not jeopardize their employment.

• Members have the right to list certain preferences in a provider.
MEMBERS' RESPONSIBILITIES

• Members have the responsibility to treat those giving them care with dignity and respect.

• Members have the responsibility to give providers information they need. This is so providers can deliver the best possible care.

• Members have the responsibility to ask questions about their care. This is to help them understand their care.

• Members have the responsibility to follow the treatment plan. The plan of care is to be agreed upon by the member and provider.

• Members have the responsibility to follow the agreed upon medication plan.

• Members have the responsibility to tell their provider and primary care physicians about medication changes, including medications given to them by others.

• Members have the responsibility to keep their appointments. Members should call their providers as soon as they know they need to cancel visits.

• Members have the responsibility to let their provider know about problems with paying fees.

• Members have the responsibility to report abuse and fraud.

• Members have the responsibility to openly report concerns about the quality of care they receive.
My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.
Patient Name*
First Last
Date*
Signature*

INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES
Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

• Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

• We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.

• You need to use a webcam or smartphone during the session.

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

• It is important to use a secure internet connection rather than public/free Wi-Fi.

• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.

• If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

• As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.
Patient Name
First Last
Date
Signature of Patient/Patient's Legal Representative

Step 1 of 8

PATIENT REGISTRATION

INSURANCE INFORMATION

SECONDARY INSURANCE (Medicare patients only)

MOTOR VEHICLE INSURANCE (Motor Vehicle patients only)

RELEASE FOR PROFESSIONAL INFORMATION

APPOINTMENT CANCELLATION POLICY

CLIENT HISTORY

MEDICAL/HEALTH INFORMATION

PAST MEDICAL & PSYCHOLOGICAL TESTS

PAST MEDICAL & PSYCHOLOGICAL HISTORY

MEDICATIONS

CURRENT HEALTH

FAMILY HISTORY

LIVING ARRANGEMENTS

ACADEMIC/VOCATIONAL HISTORY

CONSENT FOR PURPOSES OF TREATMENT & HEALTHCARE OPERATIONS

PATIENT HIPAA CONSENT

MEMBERS' RIGHTS & RESPONSIBILITIES STATEMENT

INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES

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