CBH FORMS
CBH Forms
Welcome to CBH Forms where all the forms are available in one place for your convenience!
We know filling out forms can be a pain. We made it EASY and convenient just for YOU! Forms can be filled online directly (Submit Online) or using fillable pdf or print (Fillable PDF or Print) and fill out with a pen and return to us during your first appointment.
INTAKE
CONSENT FOR OUTPATIENT TREATMENT
OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT
AUTHORIZATION FOR DISCLOSURE OF INFORMATION
- INTAKE
- CONSENT FOR OUTPATIENT TREATMENT
- OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT
- AUTHORIZATION FOR DISCLOSURE OF INFORMATION
INTAKE Information
Name
MM/DD/YYYY
Age
Gender
SS# XXXX-XX-XXXX
Address
City
State
ZIP
Home Phone
Cell
Your Email
Referred by (if any)
Marital Status
Please list children and ages
Name
Age
Name
Age
Emergency Contact
Name
Relationship
Home Phone
Cell
Insurance Information
Insurance Company
Benefits Phone#
Subscriber Name
Date of Birth
ID#
Group
CONSENT Information
Client Name
Receipt of patient Rights.
I understand the possible psychology risk involved in counseling I am hereby forewarned and cautioned, that engaging in psychotherapy may involve discussing uncomfortable past traumatic events, and /or experiencing depression, anger, anxiety, and other difficult intense emotions.
I understand that I cannot attend any session or group while I am under the influence of illegal drugs and/or alcohol.
I understand that my therapist may work with the typist, practicum student’s supervisor, and case managers regarding my treatment and /or clinical files.
I understand that certified alcohol and drugs abuse counselors, practicum students/interns, and unlicensed professionals do not have privileged communication and may be required if court ordered to testify regarding my treatment.
I understand that I have the right to receive Telehealth services which are available for most insurance plans and are offered through HIPAA-compliant, confidential software.
I understand that I need to communicate any concerns or problems I have to my therapist regarding my treatment and that I am responsible to make change occur. I understand that I am responsible for completing tasks/homework assigned by my therapist. I have read and understand the above-initiated items and received an explanation of the information.
I have read and understand the above initialed items and received an explanation of the information.
Date
Person Served Signature:
Witness:
Authority of Personal Representative:
Date
Personal Representative:
FINANCIAL Information
Name (Print):
Insurance Coverage:
Clients agree to contact the Insurance Company to verify benefits for services rendered. You pay for your insurance. It is your responsibility to know the benefits of your policy
Should a dispute arise on a claim, it is generally the clients’ responsibility to clarify and dissolve the dispute with the insurance company
If Insurance is being filed, any deductible not yet met is due at the time of service well as any co-pay
Payment:
Payment is expected at the time of service unless other arrangements have been made
I agree to provide a 24-hour notice to cancel an appointment. Otherwise, no show or late cancel charge will be assessed
If the client does not show up for a scheduled appointment, there is no show charge of $50
Services requested by the client, but not covered by the client’s Insurance Plan may be arranged under a separate written agreement with the provider
Phone calls are not billable to your insurance. Phone calls over 10 minutes are billed for the amount of time spent on the phone, at the pro-rated hourly rate
Emails – no appointments will be scheduled via email. Phone calls will be responded to within 72 hours. Appointments will only be made via phone calls
Our self-pay fees are subject to change at the discretion of the practice. A list of self-pay services and fees is available upon request
There is a $30.00 administration charge for checks that do not clear the bank . . . . . . . . .
Questions regarding your account should be directed to the Billing service at 402-590-2947
I certify that I have read, understand, and agree to the foregoing. The undersigned is the client or is duly authorized by and on behalf of the client to execute the above and accept its term.
Signature of Client
Date
Signature of Witness
Date
AUTHORIZATION Information
Disclosure of Information
Name
SS# XXX X XXX
Authorization is hereby given to exchange information in written, verbal, or electronic form regarding the above named individual between the following agencies and/or individuals to be used for the purpose(s) of:
I authorize the following agency or individual (please include address):
To release and /or receive information from the following agency or individual (please include the address):
Date
Person Served Signature:
Witness:
Authority of Personal Representative:
Date:
Personal Representative:
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