New Patient Registration

Date of Birth(Required)

Gender Identity(Required)

Phone(Required)

Email(Required)

Authorization to Leave Messages and Receive Emails

I hereby authorize that phone messages, emails, and/or text messages are allowed to be left at the above email address/ phone number(s) regarding my prescriptions, appointments, and care.

Signature(Required)

Today's Date(Required)

Emergency Contact

Relationship:(Required)

Emergency Contact Phone(Required)

Financial Responsibility

Parent/Guardian Date of Birth

Parent/Guardian Phone

Father Phone

Mother's Phone

Insurance Information

Upload A Picture Of Your Insurance Card

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Max. file size: 100 MB.

Primary Insurance Company(Required)

Insurance ID Number(Required)

Insurance Group Number(Required)

Appointments

The keeping of regular appointments is crucial to successful therapy. As the schedule permits, we will work out a most convenient time for you for these appointments. The scheduling of an appointment constitutes an agreement to pay for the professional time reserved exclusively for you. It is extremely important that you show up for your scheduled appointment with our office. Not showing for an appointment for an appointment or canceling the day of has the following impact for patients:

A missed opportunity for your health conditions to be monitored and or managed
A missed opportunity for another patient with healthcare needs who could have been seen during that time.

Our policy is to charge for missed appointments or appointments canceled with less than 24 hours notice at the rate of $100.00 You will be billed directly for this time.

Arriving Late: We ask that you arrive at least 15 minutes prior to your scheduled appointment time. Your appointment time is the time when your provider sees you in the room, please allow time to check in with the front desk. Please note that if you arrive 10 minutes AFTER your appointment time there is a chance we will need to reschedule to ensure the provider has the proper time with you and does not get behind.

Payment of Fees

I certify that I (or my dependent) have insurance coverage and assign directly to Advaita Integrated Medicine (Advaita Integrated Medicine) all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance. I also understand that I am responsible for obtaining any initial authorizations required by my insurance carrier for each separate provider that I see. I hereby authorize the doctor/therapist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Advaita Integrated Medicine requires patients to maintain an active credit, debit, or HSA card on file for the purposes of billing. This information will be maintained along with your demographic information in our secure records system. If you need to change your method of payment, please let office staff or your provider know at the time of your appointment.

Payment of any unpaid balance on an account must be received in full before the close of the month. Payments are non-refundable. You will be charged a $25 service charge for all returned checks. Unpaid balances older than 90 days will be subject to collections proceedings. This process includes the addition of a thirty-three and one-third (33 1/3) percent attorney fee to your unpaid balance. Service may be interrupted until payment is made.

Reports, Consultations, & Clerical Matters

Any reports or professional consultations involving time beyond that of the regular scheduled session will be billed at a pro-rated charge for the professional time involved. We will charge for telephone, email and/or communication consultations with your provider, which are longer than five minutes, at the usual and customary rate should your provider deem it appropriate. Psychological Testing results may not be released until the testing bill is paid in full.

*By signing below, you acknowledge, understand, and agree to comply fully with the above policies. I recognize and accept full financial responsibility for all professional services rendered.

Signature(Required)

Teletherapy Consent

I understand that teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to receiving health care services to me via teletherapy over secure video conferencing platform and other communication and electronic tools. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to teletherapy. I understand that my provider may decide that telepsychiatry is not appropriate for me, and may require me to be seen in person.

Consent To The Release Of Information

Patient agrees that his/her clinician may share information with other professional staff at Advaita Integrated Medicine (Advaita Integrated Medicine) with regard to his/her case in order to better provide quality treatment. This information will be kept strictly confidential and remain in the confines of Advaita Integrated Medicine only.

*By signing below, you acknowledge, understand, and agree to Advaita Integrated Medicine’s Teletherapy Consent and Policy and Consent to Release Information

Signature(Required)

Clinical Admissions Screening

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Consent To Treat

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Notice of Privacy Practices

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New Patient Registration

Authorization to Leave Messages and Receive Emails

Emergency Contact

Financial Responsibility

Insurance Information

Appointments

Payment of Fees

Teletherapy Consent

Consent To The Release Of Information

Friendly & Affirming