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 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
Never Married Domestic Partnership Married Separated Divorced Widowed

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:

Personal Representative/Parent Signature

FINANCIAL Information

Name (Print):

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/Parent

Date

HIPAA Compliance Information

HIPAA Privacy Notice Acknowledgment “By signing below, I acknowledge that I have been informed that my personal health information is protected by the Health Insurance Portability and Accountability Act (HIPAA). I understand that my information will be kept confidential and only shared with authorized individuals or entities, as permitted or required by law. I have been provided with a copy of the organization’s HIPAA Privacy Notice, which outlines my rights and the ways in which my information may be used and disclosed. I consent to the use and sharing of my health information as described in the Privacy Notice.

Date

Person Served Signature:

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