Patient Intake Form "*" indicates required fields Step 1 of 9 11% How Did You Hear About Us? Name* First Last Nick Name Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mobile PhoneHome PhoneWork PhoneOther PhoneEmail SexMaleFemaleMarital StatusMarriedSingleOtherSpouse/Significant Other's Name First Last Employment Language Billing Party InformationResponsible Party for Billing (Name as it Appears on Insurance Card) First Last Relationship Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile PhoneHome PhoneEmail Consent to Treatment I understand that the treatment offered by PGC Counseling, LLC is of a voluntary nature. I will make every attempt to develop my own treatment plan with the assistance of the Clinic staff and follow through with treatment recommendations developed with Clinic staff. I do hereby consent to the diagnostic and treatment procedures which the staff deem necessary as appropriate for me. I also understand that I have a right to accept or reject any and all treatment plans that are presented to me. I also understand that I am responsible for any co-pay my insurance requires. SIGNATURES OF CONSENT My/Our signatures below indicate our Consent to Treatment, as explained on this form. Date MM slash DD slash YYYY Client Signature (if over 14yrs of age)*Parent/Guardian Signature(s) Appointment Compliance My signature below indicates that as a client of PGC Counseling, LLC, I understand that I am responsible for keeping my scheduled appointments. I also understand that it is my responsibility to call at least 24 hours in advance if I need to cancel or reschedule an appointment. Due to limited appointment availability and to best serve the needs of other patients, PGC Counseling, LLC, reserves the right to charge for unattended appointments. The charge for an unattended appointment starts at a minimum of $60.00 up to the full value of the session, which is not billable to your insurance. If you are sick or feel that you may be contagious, you will not be charged for a missed appointment -even without prior notice. Your treatment team at PGC Counseling, LLC appreciates your regard for the health of our other patients and hopes you feel better soon! We will be happy to reschedule your appointment. Patient Signature Verification I hereby authorize PGC Counseling, LLC to furnish my information concerning my treatment direct to the insurer to pay, without equivocation, directly to PGC Counseling, LLC all benefits due them as a result of this claim. Although covered by insurance, I am personally responsible for all charges. A digital or photo static copy of this authorization will be valid as the original. This agreement will remain in effect until revoked by me in writing. Assignment of benefits “I understand that I may request a copy of the Assignment of Benefits Form”. Date MM slash DD slash YYYY Client Signature (if over 14yrs of age)*Parent/Guardian Signature Patient Signature Verification I hereby authorize PGC Counseling, LLC to furnish my information concerning my treatment direct to the insurer to pay, without equivocation, directly to PGC Counseling, LLC all benefits due them as a result of this claim. Although covered by insurance, I am personally responsible for all charges. A photo static copy of this authorization will be valid as the original. This agreement will remain in effect until revoked by me in writing. Date MM slash DD slash YYYY Client Signature (if over 14yrs of age)*Parent/Guardian Assignment of Benefits 1. I understand that I/We will be financially responsible for and agree to pay PGC Counseling, LLC for all services rendered to the above-named client. 2. I assert that I/my child, has no other insurance coverage except --List Any Exceptions Below-- . If additional insurance coverage is discovered at a later date, I may be held liable for the entire bill if the insurance refuses to pay. 3. I authorize PGC Counseling, LLC, to act as my agent in helping me obtain payment from my insurance company. I/We, the parents or legal guardian of the above named client, gives PGC Counseling, LLC, authorization to receive payment of any and all insurance benefits which are otherwise payable for all services rendered during the period of treatment. 5. I/We permit a copy of this authorization to be used in place of the original. “The following insurance benefits information that was collected at PGC Counseling, LLC, is true and correct to the best of my knowledge. If the insurance company does not reimburse PGC Counseling, LLC for services provided to me, I am fully responsible to pay for these services at the time of request and/or service.” “If my insurance company requires me to pay a co-pay, I further agree to pay PGC Counseling, LLC this co-pay at the time of service and/or request for payment.” “I have been offered a copy of the Assignment of Liability Form”. Insurance Exceptions if Any Date MM slash DD slash YYYY Client (age 14 and older) Signature*Parent/Guardian Signature NOTICE OF PRIVACY PRACTICES SUMMARY In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Our Privacy Practices: This is a summary of PGC Counseling, LLC Notice of Privacy Practices. PGC Counseling, LLC promises to maintain the confidentiality of your protected health information (PHI). PHI is health information about you that we have in our records. Our Notice is attached. We urge you to read our Notice. It provides a more complete explanation of your rights and our duties. Federal and State Laws: We are required by federal regulations called the “HIPAA Privacy Regulations” to protect the confidentiality of your health information. We are also required to comply with Pennsylvania laws that are more stringent than the HIPAA Privacy Regulations. If you are receiving mental health, mental retardation, or drug and alcohol abuse rehabilitation services, we will comply with the Pennsylvania laws that provide the greatest protection for your health information. Authorization to Disclose PHI: Except as described in our Notice, it is our practice to obtain your authorization before we disclose your PHI to another person or entity. You may revoke your authorization at any time. How We Use Your Protected Health Information: Our Notice explains how we may use your PHI for treatment, payment, and health care operations. For example, we may use your PHI to plan and provide your care and treatment, communicate with health care professionals, obtain payment for our services, educate and train our staff, and access and improve our services. We are also permitted to use and disclose your health information if required by law. Your Rights: Our Notice explains your rights. For example, you have the right to request a restriction on certain uses and disclosures of your PHI; inspect and copy your PHI; request amendments to your PHI; and obtain an accounting or list of disclosures of your PHI. Our Duties: Our Notice explains our obligations and duties. For example, we must provide you with a copy of the Notice upon request and comply with the terms of our Notice. For More Information or to Report Problems Please Contact our Privacy/Compliance Officer at PGC Counseling, LLC at 717-830-0705. Acknowledgement: Please sign below to indicate that you have read and understand the above principles of the Notice of Privacy Practices. Date MM slash DD slash YYYY Client (age 14 and older) Signature*Parent/Guardian Signature NOTICE OF CHANGE AS OF JANUARY 1, 2020 Insurance companies require providers to collect copays at the time of service. This can be done by check, cash or credit card. For your convenience we require that we keep encrypted credit card information on file. If you wish to use another payment method, like cash or check, please let us know; a copy of your credit card will still be kept on file. PGC Counseling, LLC utilizes technologies that are certified PCI compliant. TransArmor technology converts credit card data into secure tokens. This allows PGC Counseling, LLC to keep credit card accounts on file for future use without storing sensitive credit card numbers. ENHANCED SECURITY PGC Counseling, LLC utilizes technologies that are certified PCI compliant. TransArmor technology converts credit card data into secure tokens. This allows PGC Counseling, LLC to keep credit card accounts on file for future use without storing sensitive credit card numbers. My signature gives permission to PGC Counseling, LLC to charge my credit card for copays and any unpaid balance that goes to my deductible. Name as it Appears on Credit Card* Date MM slash DD slash YYYY Signature*Card Type*VisaMastercardDiscoverCard Number* Expiration Date* CVV#* ATTENDANCE IN COURT OR DOCUMENTATION Your treatment team at PGC Counseling, LLC best serves you in our clinic, which is where we prefer to stay. If you should request our appearance as a witness in court or should we be subpoenaed, an hourly rate of $250.00 plus additional costs as set forth below. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice, there will be an additional $250 fee in addition to the hourly rate charge for the inconvenience to other clients and administrative costs of rescheduling other matters. Also, if the case is continued, rescheduled or settled with less than 72 business hours’ notice to date of court appearance, then the client will be charged an additional $500 fee. The client hereby agrees to this court appearance and agrees to be responsible for any or all portion of which not covered by insurance. 1. Preparation time (including submission of records, filing documents): $250.00/hr 2. Phone calls: $250.00/hour 3. Depositions: $250.00/hour 4. Time required in giving testimony: $250.00/hour 5. Mileage: $0.40/mile 6. Reimbursement of all travel-related expenses and lodging 7. Time away from office due to depositions or testimony: $250.00/hour 8. Reimbursement of all associated attorney fees and costs 9. The minimum charge for a court appearance: $1500.00 My/Our signatures below indicate our Consent to as explained on this form. Date MM slash DD slash YYYY Client Signature*
