Embedded Files
To become a patient/client :
Complete Intake paperwork -please include your insurance information even if I am not a provider for your insurance,
I may still need to do prior authorizations for various medications and will need this information to facilitate your care. NOTE SIGN that you recieved privacy practices to left of intake paperwork and date and initial NSM privacy practices form (now in fillable formate bellow)
2. Complete Provider/Client Financial Agreement for all private pay patients
Forms are all in fillable format now- contact me if you have any trouble completing paperwork online
Intake paperwork below to register as a patient with me
COMPLETE THIS FINANCIAL AGREEMENT TO AGREE TO FEE PAYMENT DIRECTLY FROM YOU TO PROVIDER,
SUPERBILL WILL BE PROVIDED TO YOU TO APPLY TO YOUR INSURANCE OR HSA FOR REIMBURSEMENT DIRECTLY - note not all insurances will reimburse patient directly you have to check with your insurance.
The agreement to pay directly can be done through bellow link
Understanding my policies on taking Medicare- I request payment from patient directly , I bill 115% of medicare allowed amount-
then I submit to medicare that you paid- and they reimburse you directly see form NON par letter on next pages
MEDICARE non par- you don't need to submit superbills provider will record with MEDICARE your payment to provider and medicare will send you 80% of reimbursed amount and forward your bill to your coinsurance (in some cases these coinsurers pay provider- but provider will reimburse you that )
IF YOU NEED ME TO FORWARD INFORMATION TO YOU OR YOUR CURRENT PROVIDER , OR IF YOU NEED ME TO COORDINATE CARE WITH YOUR PCP PLEASE COMPLETE THE BELOW RELEASE AND SUBMIT TO ME INDICATING WHAT YOU NEED.
Directions for completing be sure to put in the entity you want information conveyed to and how you want it conveyed (mail, email , fax)
also INITIAL what you want released; and INITIAL box mental health/substance abuse at bottom; and sign and date at bottom
be sure to write in what information is needed and the dates of treatment (circa) and why (transfer of care, coordination of care, prior med hx etc)
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