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1.0 Adult Intake Packet


By checking this box I hereby authorize PsyCare Inc to furnish information to the above insurance carriers concerning diagnosis and treatment and I authorize the insurance carriers to forward all payments to the doctor for services rendered to my dependents or myself. I understand that I am responsible for any charges that are not covered by insurance and that the information provided above is complete and there are no other insurance policies covering services. I understand that it is my responsibility to notify PsyCare Inc of any changes in my insurance coverage otherwise I will be responsible for payments in full. This authorization will be effective as of the date entered below. A photocopy of this authorization shall be considered as valid as the original. This authorization also verifies that I have received and have read the PsyCare handbook and HIPAA notice of privacy practices. I understand that if I have any questions or need clarification, I can ask any member of the PsyCare staff for assistance. I consent to PsyCare providing me with assessment and treatment services.







FEES: The charge for the initial diagnostic interview (90791) is $255. The fee for the subsequent standard session (90837, est. 55 min) is $215. The intermediate session (90834, est. 40 min.) is $145, and brief session (90832, est. 25 min) is $110. The fee for the initial psychiatric evaluation session (90792) is $280. Subsequent medication management sessions are charged in accordance with level of complexity or time, according to AMA CPT-Code standards (99211--$35 (nurse); 99212--$80; 99213--$130; 99214--$180; 99215--$250). The fees for psychological testing and for required reports are based upon the time requirements, with a $170 charge for each hour utilized. Charges for completion of forms are $8 per 5 minutes required. Fees for specialized forensic services must be established with the clinician.

MISSED APPOINTMENTS OR LATE CANCELLATIONS: There will be no charge for appointments cancelled at least 24 hours before the scheduled appointment time. Due to the nature of psychological and psychiatric services, payment for the time reserved is necessary for late cancellations, (less than 24 hours prior to the scheduled appointment), and missed appointments. Unlike many professional practices which allow ?overbooking? and brief visits, your appointment means that you have reserved a significant amount of professional time. This is time that, for practical purposes, is lost and cannot be made up if the appointment is cancelled late. It is also time that may have been utilized for the benefit of another person with the proper advanced cancellation. Therefore, $100 will be charged for missed appointments with no prior notification, and $70 will be charged for late cancellations. These are charges that are not covered by health insurance.

INSURANCE COVERAGE: PsyCare has agreed to contractual arrangements with many insurance or managed care companies, as well as Medicare and Medicaid. The terms of these contractual agreements, which typically include allowed charges, will supersede the above fee schedule. PsyCare will make reasonable efforts to determine your specific coverage and financial responsibilities in advance of treatment; though responsibility for the accuracy of coverage details remains yours. It is the client?s responsibility to notify PsyCare of changes in coverage; and failure to notify PsyCare may result in charges to the patient due to insurance denial of payment. You will need to provide PsyCare with the necessary information describing your coverage, as well as your authorization for PsyCare to provide information required by your insurance company. It is PsyCare policy that co-payments are due at the time of service. Following the processing of the insurance claim, the insurance company typically provides an Explanation of Benefits (EOB), which identifies the patient balance due for the service, such as an amount applied to the deductible. This amount will then be due in full.

INTEREST, LATE FEES AND COLLECTION CHARGES: There is no interest charge for accounts in good standing. However, overdue accounts (accounts with patient responsibility not paid within 20 days of account statement) will be charged a $14 re-billing fee. If collection efforts become necessary, collection costs, court costs and legal fees will be added to the account balance.

PAYMENT: Cash, checks, MasterCard and Visa accepted. There will be a $30 charge for a check returned due to insufficient funds. Under special circumstances, an individualized payment plan may be established with the Accounts Manager, as follows:

All charges are based upon the current usual and customary rates for mental health services. If you have any questions, please don?t hesitate to ask. I have read and agree to the arrangements documented above. I have been offered a copy of this form.

TEXT OR EMAIL APPOINTMENT REMINDERS: To help remember appointments and reduce the number of missed appointments, you can be sent a reminder via text or email. No HIPAA related information will be sent. I authorize PsyCare to convey appointment reminders by phone, email or text. I understand that my contact information will remain confidential. I agree to the terms and conditions provided by PINGER (www.pinger.com/content/company/termsconditions.html), and I understand that I have the option to stop reminders at any time by speaking directly with a PsyCare staff member.

EMERGENCIES AND AFTER-HOURS CARE: Your therapist may be reached at one of the PsyCare offices. Emails should not be used for therapy related information. He or she will make every effort to return messages within 24 hours; however, he or she may not always be able to do that. Current clients will be notified during sessions of upcoming travel or vacation. If you have an emergency, you should go directly to a hospital emergency department or call 911. The National Suicide Prevention Lifeline number is 1-800-273-8255. Emergencies are urgent situations and require your immediate action.



This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability

A. During the last 4 weeks, how much have you been bothered by any of the following problems?

B. Over the last 2 weeks, how often have you been bothered by any of the following problems?

C. Questions about anxiety attacks.

If you checked "NO," go to question e.

D. Over the last 2 weeks, how often have you been bothered by any of the following problems?



This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please choose only one response.

In the past 30 days, how much difficulty did you have in:












If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5?D5.8, below. Otherwise, skip to D6.1. Because of your health condition, in the past 30 days, how much difficulty did you have in:



In the past 30 days:

Record number of days
Record number of days
Record number of days

Telehealth Informed Consent

The videoconference is conducted with HIPAA compliant secure technology, and your confidentiality is protected as provided in the HIPAA Notice form you were provided.


General guidelines include the following: 1) You must physically be in the state of Ohio in order to receive videoconferencing services from PsyCare Clinical Staff. 2) You must own a computer or phone capable of handling video conferencing and you need to be in a confidential location to protect your privacy during the delivery of clinical services via videoconferencing. Do not use a public or work computer or one on a shared network and do not share your password. In the event we are disconnected we will attempt to reconnect via phone. We are not a 24/7 emergency service, so if you are in crisis call 911, go to your nearest emergency room, or call or text 988. Your therapist will determine if therapy via video conferencing is appropriate for working with you.


Risks include, but are not limited to, the following: 1) A reduction of observational cues in the use of videoconferencing. 2) A risk of the loss of confidentiality due to receiving services in a location other than the Clinical Staff Member?s office, and possibly non-payment by some insurance companies.

If you want licensing information on your therapist, you can find it at one of the licensing board websites:

The Ohio Board of Psychology website at www.psychology.ohio.gov The Counselor, Social Worker, and Marriage and Family Therapist Board?s website at www.cswmft.ohio.gov The Ohio Chemical Dependency Professionals Board?s website at www.ocdp.ohio.gov The Ohio State Medical Board?s website at www.med.ohio.gov The Ohio Board of Nursing website at www.nursing.ohio.gov


By signing this Telehealth Informed Consent form, I state that I have read the above information and agree to participate in a videoconference to promote my treatment based on the above terms and conditions. I have had any questions about these services answered to my satisfaction.


Patient Rights and Responsibilities

Below is a list of your rights and responsibilities as a PsyCare Patient. This list represents current PsyCare policies that are in compliance with federal, state, and local statutes and regulations. Please read this list and then sign on the appropriate line at the bottom. You may discuss any questions with your therapist.

(1) You have the right to be treated with consideration and respect for personal dignity, autonomy, and privacy.

(2) You have the right to treatment. These rights include, but are not limited to:

(a) The right to a humane psychological and physical environment that is the least restrictive environment appropriate to your needs.

(b) The right to a current, written, individualized treatment plan, which you have participated in establishing, and to review that plan with your therapist.

(c) The right to be informed of alternative and additional treatment resources and the right to request and receive aid in referral to another agency.

(d) The right to be informed of any potential negative consequences to treatment.

(e) The right to be protected from abuse and neglect.

(f) The right to refuse medication and/or treatment.

(3) You have the right to have equitable access to treatment regardless of age, race, ethnicity, religious orientation, sex, sexual orientation, disability, or source of payment for services.

(4) You have the right to confidentiality in accordance with federal and state laws.

(5) You have the right to full disclosure of all costs and fees.

(6) You have the right to know that under the following five conditions, and otherwise allowed by law, you may have no right to confidentiality. PsyCare clinicians may have the legal responsibility to:

(a) Report suspected abuse or neglect of minors to the County Children Services Board or law enforcement.

(b) Report suspected elder or animal abuse or neglect to the appropriate county agency.

(c) Report homicidal intentions to the identified victim(s) and the appropriate legal authority.

(d) Report suicidal intentions to your family and/or the appropriate legal authority if you fail to follow treatment recommendations.

(e) Comply with requests for records if court ordered or ordered by an administrative agency.

(7) The attending clinician reserves the right to terminate treatment due to a patient?s failure to comply with treatment recommendations, abusive or harassment behavior by the patient, failure to keep scheduled appointments, and/or failure to keep contractual obligations regarding payment of fees. In that event, the patient will be provided with the names of other appropriate treatment providers.

(8) You have the responsibility to go immediately to the nearest Emergency Room if you have active suicidal and/or homicidal thoughts or to call 988. We are not a 24 hour emergency service.

(9) You have the responsibility to report to the Clinic Director or another staff member any inappropriate sexual advances, overtures, behaviors, or efforts to establish a personal relationship outside of treatment by your therapist. Under no circumstances is this behavior ethical or acceptable in a professional treatment relationship, and is entirely outside of the scope of PsyCare services. Given the privacy of the treatment relationship, PsyCare can offer protection only if we are advised regarding the behavior as soon as it first occurs.

(10) You have the right to express complaints and grievances, to have your complaints and grievances heard, and to obtain a response. You have the right to file a grievance with the Client Rights Officer by contacting PsyCare?s Standards Compliance Coordinator at 2980 Belmont Avenue, Youngstown, Ohio, at 330-759-0276 between the hours of 9:00 A.M. to 5:00 P.M., Monday-Friday.

I have read or had this form read to me, and I fully understand its contents.


PsyCare, Inc. HIPAA Notice of Privacy Practices


The mission of PsyCare is to enhance and promote the mental and emotional well-being and optimal social functioning of all persons. This mission is accomplished by providing a comprehensive and integrated continuum of outpatient mental health and related services. In conjunction with the provision of such services, at times it may be necessary for us to use and to disclose your protected health information (PHI). PHI refers to information in your health record that could identify you. It includes information about your symptoms, test results, diagnosis, treatment, and related medical information.

PsyCare is required by law to maintain the privacy of your PHI and to provide you with notice of the legal duties and privacy practices regarding PHI and to notify you following a breach of unsecured PHI. We understand that your health information is highly personal, and we are committed to safeguarding your privacy.

I. Disclosure of Your PHI Without Your Authorization

This Notice sets forth different reasons for which we may use and disclose your PHI. The Notice does not list every possible use and disclosure; however, all the reasons for which we are permitted to use and disclose your PHI are listed. The amount of health information used or disclosed will be limited to information that excludes most direct identifiers, such as name, address, and Social Security number, unless more information is needed. If additional information is needed, it will be limited to the ?minimum necessary? to accomplish the purpose of the use or disclosure.

To You: PsyCare may disclose your PHI to you, the individual who is the subject of the information.

Treatment, Payment, & Health Care Operations: PsyCare may use or disclose your PHI for treatment, payment, and health care operations purposes. Treatment is when we provide, coordinate, or manage your health care and other services related to your care. An example would be when we consult with another health care provider, such as your family physician or specialist. Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for our services to you or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of our practice. Examples of this are quality improvement activities, business-related matters (such as audits and administrative services), case management, and care coordination. Use applies only to activities within our practice, such as sharing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside PsyCare?s practice, such as releasing, transferring, or providing access to information about you to other parties.

Incidental Use and Disclosure: PsyCare may use of disclosure your PHI as a result of, or as ?incident to,? an otherwise permitted use or disclosure, as long as it has adopted reasonable safeguards as required by HIPAA and the information being shared is limited to the ?minimum necessary.?

Where Required by Law: PsyCare may use and disclose your PHI as required by law, including, but not limited to, statute, regulation, or court order.

Public Health Activities: PsyCare may disclose your PHI to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post-marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law.

Victims of Abuse, Neglect or Domestic Violence: In situations involving abuse, neglect, or domestic violence, PsyCare may disclose your PHI to appropriate government authorities.

Health Oversight Activities: PsyCare may disclose your PHI to health oversight agencies for purposes of legally-authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.

Judicial and Administrative Proceedings: PsyCare may disclose your PHI in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.

Law Enforcement Purposes: PsyCare may disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official?s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person?s death, if PsyCare suspects that criminal activity caused the death; (5) when PsyCare believes that PHI is evidence of a crime that occurred on its premises; and (6) by PsyCare in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.

Decedents: PsyCare may disclose your PHI to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.

Cadaveric Organ, Eye, or Tissue Donation: PsyCare may use or disclose PHI to facilitate the donation and transplantation of cadaveric organs, eyes, and tissue.

Research: Research is any systematic investigation designed to develop or contribute to generalized knowledge. PsyCare may use and disclose your PHI for research purposes, provided that it obtains either: (1) documentation that an alteration or waiver of individuals? authorization for the use or disclosure of PHI about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use or disclosure of PHI is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any PHI from PsyCare, and that PHI for which access is sought is necessary for the research; or (3) representations from the researcher that the use or disclosure sought is solely for research on PHI of decedents, that the PHI sought is necessary for the research, and, at the request of PsyCare, documentation of the death of the individuals about whom information is sought.

Serious Threat to Health or Safety: PsyCare may disclose your PHI if it believes such disclosure is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat).

Essential Government Functions: PsyCare may disclosure your PHI for certain essential government functions, including assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Workers? Compensation: PsyCare may disclose your PHI as authorized by, and to comply with, workers? compensation laws and other similar programs providing benefits for work-related injuries or illnesses.

Limited Data Set: A limited data set is PHI from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. PsyCare may disclose for research, health care operations, and public health purposes, a limited data set, provided the recipient of the limited data set enters into a data use agreement promising specified safeguards for PHI within the limited data set.

II. Disclosure of PHI With Your Authorization

In all other instances (including most uses or disclosures of PHI consisting of psychotherapy notes), PsyCare may use or disclose your PHI only with your authorization. ?Authorization? is written permission that allows PsyCare to disclosure specific PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that?1) we have relied on that authorization or 2) if the authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer the right to contest the claim under the policy.

We will obtain a written authorization for any use or disclosure of psychotherapy notes, except: (1) to carry out the following treatment, payment, or health care operations: use by us for treatment; use or disclosure by us for our own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or use or disclosure by us to defend ourselves in a legal action or other proceeding brought by you; and (2) a use or disclosure that is: required by the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule; permitted by law; for health oversight with respect to the oversight of our operations; to a coroner or medical examiner for the purpose of identifying a decedent; or to avert a serious threat to health or safety.

III. Disclosures That Will Not Be Made

Please note that we do not use your PHI for marketing or fundraising efforts. We do not sell your PHI. We also do not use or disclose your genetic information PHI for underwriting purposes, which is prohibited by the Genetic Information Nondiscrimination Act (GINA) of 2008.

IV. Your Rights under HIPAA

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI; however, we are not required to agree to a restriction at your request except for restrictions for any disclosures to be made to a health plan for payment or health care operations functions (but not for treatment purposes) involving a health care item or service for which you have paid us out of pocket in full.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are receiving services at PsyCare. Upon your request, we will send your statements to another address.

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI records used to make decisions about you for as long as the PHI is maintained in the record. If the we maintain your PHI in an electronic format (including in an electronic health record), you have a right to obtain a copy of such information in an electronic format and, if you so choose, direct us to transmit such copy directly to another entity or person. We may deny your request to inspect and copy your PHI in certain limited circumstances. In some circumstances, you may request that the denial be reviewed.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. On your request we will discuss with you the details of the amendment process. We may accept or deny your request.

Right to an Accounting: Generally, you have the right to receive an accounting of disclosures of PHI for which you have not provided either consent or authorization (as described in Section III of this Notice). You also have the right to request an accounting of disclosures of your PHI through an electronic health record made by us to carry out our payment activities or health care operations within the past three years from the date of your request. On your request, we will discuss with you the details of the accounting process.

Right to a Paper Copy: You have the right to obtain a paper copy of the notice from PsyCare upon request, even if you have agreed to receive the notice electronically.

Right to Receive Notification: You are entitled to receive notification from us if the confidentiality of any of your PHI maintained in an unsecured form is compromised.

V. PsyCare?s Duties Under HIPAA

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice. We are required to abide by the terms currently in effect, unless we notify you of such changes.

We reserve the right to change the terms of this notice and to make the provisions of the new notice effective for all PHI that we maintain. If we revise our policies and procedures that will affect your PHI, we will send a notice of these changes to you by regular mail to your last known address that we have on file for you.

VI. Questions and Complaints

If you have questions about this notice, disagree with our decision about access to your records, or have other concerns about your privacy rights, you may contact the Privacy Officer for PsyCare, in writing, at PsyCare, 2980 Belmont Avenue, Youngstown, Ohio, 44505, or by phone at 330-759-2310.

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to the Privacy Officer at PsyCare, 2980 Belmont Avenue, Youngstown, Ohio, 44505.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, SW, in Washington, D.C., 20201.

We will not retaliate against you for exercising your right to file a complaint.

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