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Registration Packet

INSURANCE BENEFITS AND PRIVACY PRACTICES

INSURANCE BENEFITS AND PRIVACY PRACTICES

ASSIGNMENT AND COORDINATION OF INSURANCE BENEFITS

  • I agree to provide information regarding all group hospitalization, health maintenance organization, Workers' Compensation, automobile, and other health care benefits (“Insurance Plan(s)”) to which I may be entitled. I hereby assign payment(s), if any, from my Insurance Plan(s) to New Beginnings (or its affiliate) and each of the independent contractor physicians and/or professional corporations for services rendered to me. The direct payment hereby assigned and authorized includes any Insurance Plan(s) benefits to which I am otherwise entitled, including any major medical benefits otherwise payable to me under the terms of my policy, but is not to exceed the balance due to New Beginnings (or its affiliate), the independent contractor physicians and/or professional corporations for services rendered to me during the applicable periods of medical care.

UNAUTHORIZED, NON-COVERED, OR OUT OF PLAN SERVICES

  • I understand if my Insurance Plan(s) does not consider this admission or any service rendered during this admission a covered service or has not authorized this service, they will not pay for this admission or the service rendered during this admission or outpatient visit. I agree to be fully responsible for payment to New Beginnings for this admission or any service if determined by my Insurance Plan(s) to be a non-covered service. I also understand and acknowledge that in the case of Out of Plan/Network services, there may be reduced benefits and I may be required to pay a larger co-payment, co-insurance or other charge in the event my Insurance Plan(s) does not reimburse these services provided to me, I acknowledge I will be responsible for any remaining balance.

FOR MEDICARE/MEDIGAP RECIPIENTS ONLY

  • I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made on my behalf to the Hospital and/or independent contractors for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for the related services. In the case of Medicare Part B benefits, I request payment either to myself or to the party who accepts assignment.

RESIDENTS, INTERNS OR MEDICAL STUDENTS

  • I understand residents, interns, medical students and other health care professional students may participate, under the supervision of an attending psychiatrist or clinician or other health care professional, in my care as part of the New Beginnings education programs.

CONSENT TO DISLOSE HEALTH INFORMATION

  • I understand and agree that /new Beginnings may use and disclose protected health information for treatment, payment, or health care operations. I understand I must consent to this use and disclosure in order to receive services through New Beginnings. I understand I have the right to review the privacy notice prior to signing this form. I understand that I have the right to request that New Beginnings restrict how protected health information is used or disclosed to carry out treatment, payment, or health care operation.

  • I hereby authorize New Beginnings to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to ne needed to substantiate payment for such medical or psychiatric services as well as information required for precertification, authorization or referral to other providers.

NOTICE OF PRIVACY ACT (HIPPA)

  • Health insurance portability and accountability act of 1996 (HIPPA) privacy regulations grant patients six right in connection with protected health information. Patients have the right to request limits on uses and disclosures of their protected health information, the right to choose how health information is sent, the right to see and obtain copies o f their protected health information, receive a list of disclosures a facility has made with their protected health information, the right to request corrections and updates, an receive the notice of privacy by email, if they choose.

NOTICE OF PRIVACY PRACTICES

  • I certify that I have been made aware of New Beginnings Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of New Beginnings operations. The Notice also describes my rights and New Beginnings duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available in the registration areas of each facility and on New Beginnings website at www.newbeginningsservices.com. New Beginnings reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

  • I certify I have read and understand the foregoing, have had the opportunity to ask questions and have them answered and accept the above conditions and terms and I agree to pay all charges for which I may be legally responsible including, but not limited to health insurance deductibles, co-payments, and non-covered. I also agree in the event my account must be placed with an attorney or collection agency to obtain payment, I will pay the reasonable attorneys' fees and other collection costs incurred by New Beginnings. I understand and agree this document will remain in effect for all future outpatient or mental health office visits to New Beginnings, unless specifically rescinded in writing by me.

REGISTER FORM

REGISTER FORM

HEALTH HISTORY FORM

HEALTH HISTORY FORM

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ALCOHOL ASSESSMENT TOOL

ALCOHOL ASSESSMENT TOOL