Patient Online Forms By filing these forms online, you will make your first visit easier. Allow 10-20 minutes to complete. You will still need to sign some of these forms at the office. Step 1 of 4 - Client Information 25% Client InformationPatient Name* First Last Date of Birth* Month Day Year Sex* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status* Single Married Divorced Social Security Number* Email Phones*Home (landline)CellWorkAt least one must be entered.May we call you at Home? Work? Cell? Would you like to be reminded of an upcoming appointment? Yes No How would you like us to remind you? Text (cell phone) Email Home phone Medical InformationPhysician's Name Dr.PANP Prefix First Last Suffix Date of last physical exam By whom were you referred to this practice? Are you on any regularly prescribed medications?* Yes No Please list your medications If you are on more than one med, after entering the first one, click the plus (+) sign at the end of the row. Continue this process until you have entered all your meds.Spouse/Parent InformationPerson I'm entering info for is Spouse Parent Neither Spouse/Parent Name Date of Birth MM slash DD slash YYYY Sex Male Female Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status Married Single Divorced Social Security # Home PhoneWork PhoneCell PhoneMay we call you at Home? Work? Cell? Employer Spouse/Parent Email Others living in your householdListNameDOB If more than one, click the plus sign (+) at the right end of the line.To whom shall we mail your monthly statement? Please note that we will bill charges to your insurance carrier if you desire. However, a statement will be mailed to you each month as well. You are responsible for payment of all charges until your insurance company pays.Responsible Party* Relationship to Client Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Responsible party's phone(s)*Home (land line)WorkCellEmployer In Case of Emergency, please contact:Name PhoneRelationship to Client Please read the following information and ask your therapist about any questions you might have. Please sign acknowledging that you understand this information and give voluntary consent to participate in treatment. COUNSELING AND PSYCHOTHERAPY: Counseling and psychotherapy attempt to help you develop alternative ways of coping with problems in living. The practice of counseling and psychotherapy is not an exact science and no guarantee exists that you will automatically feel better. Although most people do feel better, some people initially feel worse. CONFIDENTIALITY: Information which you provide to your therapist is confidential and cannot be released without your written authorization; however, some limitations to confidentially exist. Under the following circumstances, information may be released without your permission to the appropriate authorities: 1) To prevent serious, foreseeable and imminent harm to you or another identifiable person; 2) If you report an incident or any suspicion of child abuse or neglect to your therapist; or 3) If you make your mental status a court issue or a judge orders release of your records. In the event your therapist is unavailable, your therapist may give necessary information to another therapist who is on call for his or her clients’ needs. This information is to facilitate your treatment in your therapist’s absence. Your signature below authorizes such a release of information. REGARDING HANDICAP ACCESS: Attempts are made to serve all clients regardless of and disability which may exist. Handicap-access offices are available for wheelchair patients. Unfortunately, restroom facilities that accommodate wheelchairs are not available. Because of the limitations of the facility, we are happy to make alternate arrangements in order to meet your therapy needs. Please discuss these needs with your therapist. EMERGENCY SERVICE: In case of an emergency after office hours, an answering service will answer your call. Simply telephone 273-7292 and the answering service will notify your therapist or another therapist who is on call. If you are unable to reach your therapist, you may also call any of the following emergency numbers for assistance: Stormont Vail West: 1-785-270-4600 Stormont Vail Emergency Services: 1-785-354-6100 St. Francis Hospital Emergency Department: 1-785-295-8090 Shawnee Community Mental Health Center: 1-785-233-1730 Consent* I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE INFORMATION:*Hidden I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE INFORMATION:Client 2 Name First Last Client 2: I have read, understand and agree to the above information: Yes HiddenDate MM slash DD slash YYYY Do you want your visits submitted to your insurance company?* Yes No Insurance InformationName of Primary Insurance Company ID # Group # Authorization # (if available) Name of Insured First Last Date of Birth MM slash DD slash YYYY Other family members listed on this policyNameDOBRelation to Insured If more than one, click the plus (+) sign at the right of the line.Does your policy require preauthorization for services?* Yes No Don't Know Did you contact your insurance company prior to today’s visit? Yes No Do you have other insurance coverage? Yes No Please upload a copy of your secondary insurance cardMax. file size: 128 MB.Although we do not routinely submit secondary claims, we do need to indicate that coverage on claims to your primary carrier. You will be responsible for submission of claims to secondary carriers. If you are covered under Medicare, please note that your claims will be forwarded to your supplemental policy as well as to MedicarePlease read the linked documents below and check the boxes indicating your agreement. I have read and agree to the provisions of the Insurance Release document. I have read and agree to the provisions of the Patient Financial Responsibility Statement. I have read and agree to the provisions of the Payment Policy. I have read and agree to the provisions of the Notice of Privacy Practices. I have read and agree to the provisions of the Consent to Treat document. I have read and agree to the provisions of the Teletherapy Informed Consent. I have read and agree to the provisions of the Notice of Right to a “Good Faith Estimate.” When you arrive at the office for the first time, there will be some additional pages for you to sign and date. You can save time by familiarizing yourself with these documents online.EmailThis field is for validation purposes and should be left unchanged.