LHL-Adult New-patient Wilmington Total Packet Interactive Form

Page 1

ADULT NEW PATIENT Packet DEMOGRAPHIC SHEET

First Name

Middle Initial

Last Name

Goes by

Sex M F

Date of Birth

Age:

Street Address

City, State, Zip

Mobile Number

Email Address

Contact Number

SSN

Employed by or retired from

Occupation (indicate if student)

Person responsible for payment

Street Address, City, State, Zip

Same as above

Therapist

Therapist Phone

Primary care provider

Primary care provider phone

Referred by

INSURANCE

Primary Coverage

Insurance Company

Address

Phone

Employer

Subscriber’s Name

Subscribers DOB

Subscribers ID #

Group #

RxBin #

PLEASE ATTACH YOUR INSURANCE CARD(S) SO WE CAN KEEP A COPY FOR OUR RECORDS. THANK YOU

FINANCIAL RESPONSIBILITY

Payment is due at the time of service. Upon request, the office will provide you with the information needed to submit an insurance claim. If reimbursement is due, they will submit directly to you.

Signature of Patient or Legal Guardian

Date

Print Name:

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Termination:

Termination of treatment will occur for non-compliance with your treatment plan or office policy. Termination of treatment will be immediate for any inappropriate or illegal behavior towards your provider or staff.

HIPPA Privacy Notice:

I, the patient or guardian, understand that the "HIPAA Privacy Notice" is clearly posted at LH Langley, PLLC, and that I may view and request a copy of it at any time. The HIPAA privacy notice regards the privacy and protections of my treatment information at LH Langley, PLLC. I understand that treatment records are the sole property of LH Langley, PLCC. I have been notified that release/disclosure of information may only occur with consent unless it is an emergency or for other exceptions as detailed in the General Statutes of in 45 CFR 164.512 of HIPAA.

Release of Information/Authorization to Exchange My Health Information:

If there are other physicians, therapists, or providers involved in your care, please complete a Consent for Release of Information/Authorization to Exchange My Health Information form for each of them.

Stimulant Medication Shortage:

There is an ongoing shortage of stimulant ADHD medications that started in February 2023. There is no indication that this will end anytime soon. All stimulant medications are affected.

Please understand that I will do the best I can to keep you on a medication that works well for you, but I will not be able to increase the dose of your medication because that is all the pharmacy has in stock.

Additionally, I cannot make any promises about the pricing of stimulant medications, nor do I have any control over the pricing.

Finally, some pharmacies are beginning to change their company policies regarding stimulants, stimulant prescriptions and co-pay cards. This may impact where you are able to fill your prescriptions. I do not have any control over these changes and will do my best to stay informed as things change so that your treatment plan is minimally impacted.

Signature of Patient or Legal Guardian

Date

Printed Name of patient

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Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the coronavirus. Although we have taken measures to provide social distancing in our practice, social distancing is not possible at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

Yes No

Patient Name

Signature of Patient or Legal Guardian

Date

Print Name:

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Recurring credit/debit card payment authorization FORM

Patient Name:

DOB:

I understand and authorize LH Langley, PLLC to charge the credit/debit card on file the amount due at the time services are rendered. I also understand that this card will be charged the full fee for service if I do not give 48-hour notice of cancellation or if I miss/No Show the appointment. This fee is outlined in the Office Policies Form.

Name On Card:

Mastercard Visa

Credit Card Number:

Expiration Date:

CVV code:

Billing Address:

Billing Zip Code:

Signature of Patient or Legal Guardian

Date

Print Name:

I authorize the above named business to charge the credit/debit card indicated in the authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termation of this authorization at last 7 days prior to the next appointment. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit/debit card and that I will not dispute the scheduled payments with my credit/debit card company provided the transactions correspond to the terms indicated in this authorization from.

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This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please read it carefully and ask any questions if you are uncertain of the meaning of anything described below.

Your Rights

When it comes to your health information, you have certain rights. This explains your rights and some of our responsibilities to help you.

You have the right to:

Request a copy of your paper* or electronic medical records.

Electronic Record. On request, we will give you instructions on how to gain access to your electronic medical record. Your electronic medical record contains copies of your medication lists as well as some lab results

*Written Therapy Records. Due to the private nature of these records, we have a procedure to request a hard copy of your treatment records that requires you to make a time to come in to our office to review the record at a time the doctor is present to answer any questions you may have. This policy is for the purposes of keeping your information private as well as for your understanding of the information your records contain. We will make every effort to accommodate your request promptly and as a time that is convenient to you. There are no exceptions to this policy.

Request Records be sent to another provider. With a signed Release of Information, we will send your records to another medical or psychiatric provider immediately.
Correct your paper or electronic medical record (in writing). You can ask us to correct health information about you that you believe is incorrect or incomplete and we will address your request in writing within 60 days to explain if your request is possible or not.
Request confidential communications. You can ask us to contact you in a specific manner for example, home, mobile, office phone or to send mail to a different address. Most often we are able to accommodate all reasonable requests.
Ask us to limit the information we share. You can ask us to use or share certain health information for treatment, payment or insurance operations. We will always consider your privacy and will accommodate most general requests for limiting information however, in some cases for example, if we believe it will affect your care, we may not agree to your request. For insurance purposes, claims to your insurance company will contain some private information but you can ask us not to submit claims on your behalf. However, in some instances when a law requires us, we may share some private information with your insurance company.
Get a list of those with whom we have shared your information. You can request from us a list of the times we have share your health information for the past 6 years that will include who we shared your information with, what information was shared and for what purpose it was shared. PLEASE NOTE, we are unable to share your private information without a signed Release of Information from you.
Get a copy of this privacy notice. You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a copy promptly
Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
File a written complaint if you believe your privacy rights have been violated. We protect with your private health information with the highest level of confidentiality. However, if you believe your privacy rights have been violated, we would request that you contact us immediately. You also have the right to file a complaint with the US department of health and human services office for civil rights by sending your complaint in writing to 200 Independence Avenue, S.W., Washington, DC. 20201 or by calling 877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
Choose who we can share your information with.

For certain health information, you can tell us your choices about what we share and with whom. If you have a clear preference for how we share your information, please talk to us and advise us what your instructions are.
- You have both the right and choice to instruct us to share information with your family, close friends, or others involved in your care. However, if you are unable to tell us your preference, for example if you are unconscious, we may share relevant information if we believe it is in your best interest. We may also share you information when needed to lessen a serious and imminent threat to health and safety.
- We do not share most psychotherapy and therapy visit notes without your specific permission, in writing, to do so.

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Our uses and disclosures

We typically use or share your health information in the following ways:

To treat you. We can use and share your information with other professionals who are treating you. For example, a doctor treating you for an injury or condition may ask another doctor about your overall health condition.
To run our practice. We can use and share your health information for the general running of our practice, improve your care and to contact you when necessary. For example, we use health information about you to manage your treatment and services.
Bill for your services. You may ask us to bill your insurance company for the services you receive which will include your health information. Other entities such as life insurance requests for records may entail sharing your health information but require your signed approval.

Help with public health and safety issues. We are allowed, in some cases, to share your information in other ways for the purposes of public health and research. We have to meet many conditions in the law before such information for these purposes can be shared. For more information, please see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. These conditions may be certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, prevent or reducing a serious threat to anyone’s health or safety are examples. We can also use or share your information for health research.
Comply with the law. We will share information about you if state or federal laws require it, including the department of health and human services if it wants to see that we have complied with federal privacy law.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director when an individual dies.
Address workers’ compensation, law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law and other government requests such as military, national security and presidential protective services.
Respond to lawsuits and legal actions that allows us to share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you also have the right to change your mind and revoke the authorization by informing us in writing.
For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice

We can change the Terms of This Notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our web site.

Patient Name

Date of Birth

Signature of Patient or Legal Guardian

Date

Print Name:

Page 13

I am engaging in email/text communication with my provider realizing that, because there is no way to absolutely secure any electronic exchange of information, the probability of compromise of confidentiality of personal medical information is increased compared to face-to-face information exchange. As such, email/text communication on personal medical matters should be limited as possible and reserved for situations not practically allowing for face-to-face communication. No guarantee is made for the timely receipt of email or text communication, and no guarantee of response is made.
Notwithstanding the above, email/text communication should, as much as possible, avoid discussion of highly sensitive medical matters that could be, in the event of an information leak, harmful personally or publicly to the patient and/or their agents. In a word, remote communicating is a minimally controlled circumstance. Language used should be careful, deliberate, and avoid "emotionally charged" terms.
Email/text medical communication is a convenience and intervention, not a substitute for proper face-to-face medical encounters. Habitual, ongoing use of email/text for communicating medical information is discouraged in the best interests of medical professionals and patients and their agents.
I understand that it is my responsibility to update my email address or cell phone number listed below should either change.
By signature, I indicate that I have read the above content and policy of my healthcare provider and I agree to abide by the principles and spirit set forth in this document. I further understand the risks and limitations of transmission of medical information communication electronically, and so release from all and any liability my healthcare provider for any unauthorized disclosure or leak of such information inadvertently to parties outside the intended senders and recipients of such communications. I will not hold responsible the sender of medical information by email for any delays in receiving such communications and resulting harm from such delays. I am aware that when communicating from the workplace some companies consider email "at work company property," and such messages may be monitored and read by the company's officials.

Furthermore, email sent to your home may be intercepted by others. Email/text sent to your doctor's office, though directed to a specific individual, may be read by other than the designated recipient since all incoming messages in a medical facility must be reviewed timely, including when a staff member is absent for any reason. Finally, communicating by email/text always exposes both parties to the risk of computer software virus invasion which can jeopardize and destroy databases and software. By signing this, I release from any liability for damage from computer viruses my healthcare providers and their staff.
I also release my healthcare provider with whom I am communicating voluntarily in medical matters by email/text from any adverse effects such information has on me or my agents that might have been otherwise avoided or lessened by exchange of such information in face-to-face encounters. Taking all of the above into consideration, I wish to engage in email/text communications regarding my personal medical information or that for which I am a responsible agent. I have had an opportunity to ask questions on all the aforementioned and provide my consent freely.

Email Address

Mobile Number

Signature of Patient or Legal Guardian

Date

Print Name:

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This form is intended to provide information about telemedicine visits, which are different from in-person office visits and require separate consent from the patient.

Telemedicine uses audio and video technology to enable health care providers to have visits in real time with patients who are not physically present in the office.
During a telemedicine visit, the information obtained, such as medical history, examinations, diagnostic imaging, and/or test results will be used for diagnosis, treatment, follow-up, and/or education. Communication will be through live two-way audio and video, so that the patient can talk with the provider.
Consenting to receive telemedicine visits does not mean that all future visits will be via telemedicine.
The provider has the right to determine whether or not any given patient visit is appropriate to be conducted via telemedicine. The provider and the patient both have the right to discontinue the visit at any time.
The records of telemedicine visits will become part of the patient's medical record. All existing laws regarding your access to medical information and records apply to telemedicine visits.
There are technology related risks in using telemedicine, such as problems with transmission (such as low resolution or interruption in the signal and/or deficiencies or failure of telecommunications equipment. These may interfere with proper evaluation of the patient. In addition, the transmission is encrypted, and other measures have been taken to prevent unauthorized parties from accessing the transmitted information.
Please protect your email and portal passwords, and notify the practice of changes of email address or cell phone number.
This telemedicine visit will follow the same process for billing and payment for an in-person, face-to-face visit.

I have read and understood the information provided above regarding telemedicine, including the risks associated with online communication, and all of my questions about telemedicine have been answered to my satisfaction. I give my consent for the use of telemedicine for my care at LH Langley, PLLC

Signature of Patient or Legal Guardian

Date of Birth

Print Name:

Date

Relationship to Parent

Self

Parent/Legal Guardian (for children under age of 18)

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Good Faith Estimate for Health Care Services and Items for Self-Pay Patients

Services Provided by Lauren Langley, DNP, MSN, PMHNP-BC NPI: 1104063676
Services Provided at LH LANGLEY, PLLC Office EIN: 46-0725086

Date:

Patient Name:

DOB:

CPT Code(s)-Primary and Secondary

99205 Psychiatric Evaluation $400
99213 Medication Management $175
99214 Medication Management $200
99215 Medication Management $255
90833 Brief Psychotherapy $120
90836 45-minute psychotherapy $200

ICD-10 Diagnostic Code(s): Specific diagnoses discussed during treatment.

F39 (Mood Disorder)
F32.A (Depression)
F41.1 (Generalized Anxiety)
F41.0 (Panic Disorder)
F42.9 (Obsessive Compulsive Disorder)
F40.10 (Social Anxiety)
F90.9 (Attention Deficit Disorder)
G91.3 (Oppositional Defiant Disorder)

*Medication management visits are expected to be recurring. The frequency of appointments and type of appointment may vary based on current needs/symptoms. **This is a detailed list of estimated charges for psychiatric care with Lauren Langley. The estimated costs are valid for 12 months from the good faith estimate.

Disclaimer:
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Signature of Patient or Legal Guardian

Date

Print Name:

Thank you!

ADULT NEW PATIENT Packet DEMOGRAPHIC SHEET

INSURANCE

Primary Coverage

FINANCIAL RESPONSIBILITY

PERSONAL HISTORY

PERSONAL AND FAMILY MEDICAL HISTORY

PERSONAL AND FAMILY PSYCHIATRIC HISTORY

SOCIAL HISTORY

BACKGROUND HISTORY

EDUCATION

OCCUPATIONAL HISTORY

RELATIONSHIP HISTORY

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

office policies

Supplemental Informed Consent: Treatment in the era of covid-19

Recurring credit/debit card payment authorization FORM

Privacy Practices

NOTICE

Your information. Your rights. Our Responsibilities

Your Rights

Our uses and disclosures

Our Responsibilities

Changes to the Terms of This Notice

Patient's Acknowledgement OF RECEIPT TO
NOTICE OF privacy PRACTICES

E-MAIL AND TEXT MESSAGE MEDICAL COMMUNICATION INFORMED CONSENT

Telemedicine Consent Form

Consent To The Use of Telemedicine

Good Faith Estimate for Health Care Services and Items for Self-Pay Patients

ADULT NEW PATIENT Packet DEMOGRAPHIC SHEET

INSURANCE

Primary Coverage

FINANCIAL RESPONSIBILITY

PERSONAL HISTORY

PERSONAL AND FAMILY MEDICAL HISTORY

PERSONAL AND FAMILY PSYCHIATRIC HISTORY

SOCIAL HISTORY

BACKGROUND HISTORY

EDUCATION

OCCUPATIONAL HISTORY

RELATIONSHIP HISTORY

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

office policies

Supplemental Informed Consent: Treatment in the era of covid-19

Recurring credit/debit card payment authorization FORM

Privacy Practices

NOTICE

Your information. Your rights. Our Responsibilities

Your Rights

Our uses and disclosures

Our Responsibilities

Changes to the Terms of This Notice

Patient's Acknowledgement OF RECEIPT TO NOTICE OF privacy PRACTICES

E-MAIL AND TEXT MESSAGE MEDICAL COMMUNICATION INFORMED CONSENT

Telemedicine Consent Form

Consent To The Use of Telemedicine

Good Faith Estimate for Health Care Services and Items for Self-Pay Patients

Patient's Acknowledgement OF RECEIPT TO
NOTICE OF privacy PRACTICES