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FORMS

NEW CLIENT FORM

NEW CLIENT FORM

To Whom It May Concern:

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You will find the paperwork that needs to be completed before your appointment. Please fill out the paperwork completely. If your appointment is in person, you may bring the paperwork with you, along with your insurance card, or you can download and complete the forms electronically and email to admin@mycordell.com. If the appointment is for an Adult, fill out the Adult Background forms. If the appointment is for a child, fill out the Child Background form.

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If your appointment is a video appointment, we will call to schedule your appointment once we have received your completed paperwork and a copy of your insurance card.

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Please call (937) 276-3356 if you have any questions about completion of this paperwork.

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Thank you.

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Cordell Associates, LLC

WELCOME!

We provide psychological services here for individuals from early childhood through later adulthood. Open communication is an important part of seeking and receiving help. If you have any questions or concerns, please feel free to ask your therapist or the office manager. This would also apply to any complaints that you may have regarding the care that you receive here. If your concerns are not resolved satisfactorily, please call Dr. Gunn who will strive to address them to your satisfaction.

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Payment

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The fee for the first session is $150. The fee for each subsequent session is $130. Most sessions last up to one hour. Health care policies typically provide some coverage for psychological services. It is your responsibility to call your insurance company to determine your mental health benefits. Your benefits office will be able to tell you whether your deductible has been met and inform you of the co-pay and/or coinsurance amount due for each session. Keep in mind, mental health copays are often higher than the standard medical office visit.

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When you are unsure of your specific copay, coinsurance, and/or deductible amount, a standard rate of $130 is due at each session. Once your co-pay amount is known, we will adjust the payment and your account. Payment arrangements can be discussed with the office manager. We accept Mastercard, Visa, American Express, Discover, personal check, and cash.

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If your insurance changes during your course of treatment, or if you receive a new insurance card, it is your responsibility to notify our office. Companies issue new cards periodically. They may look the same, but in some cases, there are significant changes about which we need to know.

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Please keep in mind that you will be responsible for any deductible amount and the remaining portion of the bill not covered by insurance; the responsibility for paying the fee remains with you. Further, our office expects that copays, if due, be paid at each office visit, and that all accounts be kept current. Accounts that are unpaid after 90 days, without a payment plan in place, may be sent to collections.

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If you find it necessary to cancel a scheduled appointment, kindly give as much notice as possible. This allows your therapist to accommodate other clients. Please give a minimum of 24-hours notification. Repeated late cancellations/no shows may result in a fee of $30 per missed session (not billable to insurance). If appointments are consistently missed without advance notification, we reserve the right to suspend services.

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Typically, therapy or evaluations initiated by a client are not appropriate for involvement in court proceedings. In the unusual circumstance that you subpoena your therapist for a Court appearance, there is a standard fee is $250 per hour for time spent in the courtroom, travel, and preparation time. Any court-related fees and evaluations that are court-ordered require a separate consent process, and payment in advance (such services are not reimbursable by insurance). Please refer to Confidentiality, Section 6 for more information on court appearances.

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Emergency Services

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In case of a life-threatening emergency, immediately call 9-1-1. If you need to speak to your/your child’s therapist urgently, but it is not a life-threatening emergency, call the office at (937) 276-3356. An after-hours answering service will attempt to reach your therapist as soon as possible for urgent matters.

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This practice is dedicated to maintaining the privacy of your personal health information. You, as the client, have the right to have your communications and records held in confidence by your psychologist or therapist. This is called confidentiality. With certain exceptions, your psychologist or therapist may release confidential information only with your authorization, or, for minor clients, only if authorized by the custodial parent/guardian. For example, you might request that a report be sent to a medical provider, school, agency, etc. Any contact with your family, relative, minister, lawyer, or others will occur only with your written approval. Please do NOT sign to release your confidential records or those of your children in a court related matter without first discussing this with your clinician. For more information on requesting court-involvement, please see below. Others who participate in sessions with identified clients (such as spouses) do not have any rights to access (or request that others can access) your personal health information without your written consent.

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The right of confidentiality is not absolute. There are instances in which your psychologist or therapist has the legal obligation to share information with others. These circumstances include:

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1. When there is clear and imminent danger to yourself or society. In a valid emergency or life-threatening situation and after the most careful deliberation, only relevant information would be revealed to the appropriate professionals or organizations who are able to help prevent or reduce that threat. This helps ensure the safety of you and others. Your therapist will try to work cooperatively with you in any such instance. The law protects the therapist who must disclose information about an individual who is dangerous and must be hospitalized.

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2. Psychologists and therapists are required by law to immediately notify the appropriate agency or the police when there are incidents of suspected abuse or neglect of a child, elderly or disabled person. If your therapist knows or suspects that abuse or neglect of such individuals has occurred, they are obligated to report it.

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3. When ordered by a judge to respond to particular questions or to release records.

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4. If a law enforcement official requires us to do so

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5. For Worker’s Compensation and similar benefit programs.

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6. When the psychologist or therapist is working as the “agent of another”, such as in court-ordered evaluations or treatment. In these circumstances, the psychologist or therapist provides a detailed report to the court and to the attorneys on the findings of the evaluation. It is understood that this is not a confidential process as the court and the attorneys will receive clinical information and recommendations made by the psychologist or therapist. It should be noted that clientinitiated evaluation and/or treatment does not satisfy the legal requirements for a court-ordered evaluation and/or treatment. For court-involved cases, please refer to the Court-ordered Evaluation Form and discuss with your therapist or evaluator.

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7. Non-custodial parents have rights to information about the evaluation and/or treatment of their children unless a court order specifies otherwise.

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Confidential information is also released when we submit claims to your health insurance company. The standard information they receive includes dates/times of service, types of service rendered, the fees, and the diagnosis. While unusual, a managed care company may require us to disclose additional health information to justify past or continued services.

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Your records or your child’s will be kept confidential in accordance with the law regarding the practice of psychology. By signing a separate consent form, you may authorize your psychologist or therapist to contact or to send information to another professional such as a medical provider.

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In an effort to provide quality care, your psychologist or therapist may review your case with one or more consultants following the guidelines of confidentiality. Such consultation enables us to provide you with the best possible care.

CLIENTS RIGHTS AND RESPONSIBILITIES

Clients have the right to:

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  • Be treated with personal dignity and respect.

  • Care that is considerate and respectful of their personal values and belief systems.

  • Personal privacy and confidentiality of information.

  • Receive information about practitioners, clinical guidelines, as well as their rights and responsibilities.

  • Reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age or disability.

  • Participate in an informed way in the decision-making process regarding their treatment planning.

  • Discuss with their providers the medically necessary treatment options for their condition regardless of cost or benefit coverage.

  • Individual treatment, including:​​

    • Adequate and humane services regardless of the source(s) of financial support.​

    • Provision of services within the least restrictive environment possible.

    • An individualized treatment plan.

    • Periodic review of the treatment plan.

    • An adequate number of competent, qualified, and experienced professional clinical staff to supervise and carry out the treatment or program plan.

  • Participate in the consideration of ethical issues that arise in the provision of care and services, including resolving any conflicts that may arise.​​

  • Voice complaints or appeals about the care provider and to make recommendations regarding responsibilities policies.

  • Be informed of any expectations regarding their conduct.

  • Custodial parents and legal guardians of clients under the age of 18 have a right to be involved in the treatment planning process.

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Clients have the responsibility to:

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  • Give their provider information needed in order to receive care.

  • Follow their agreed upon treatment plan and instructions for care.

  • Participate, to the degree possible in developing mutually agreed upon treatment goals with their provider.

I have been given a copy of the Notice of Privacy Practices.

(Initials)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

NOTICE OF PRIVACY PRACTICES

Privacy is a very important concern for all those who come to this office. It is also complicated because of federal and state laws and our profession. Because the rules are so complicated, some parts of this Notice are quite detailed and you probably will have to read them several times to understand them. If you have any questions, our Privacy Officer will be happy to help you. Her name and telephone number are at the end of this Notice.

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Contents of this Notice

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A. Introduction - To Our Clients

B. What we mean by your medical information

C. Privacy and the laws about privacy

D. How your protected health information can be used and shared

1. Uses and disclosures with your consent

A. The basic uses and disclosures - for treatment, payment, and health care operations.

B. Other uses and disclosures in healthcare

2. Uses and disclosures requiring your Authorization

3. Uses and disclosures not requiring your Consent or Authorization

4. Uses and disclosures requiring you to have an opportunity to object

5. An Accounting of disclosures we have made

E. If you have any questions or problems

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A. Introduction - To Our Clients

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This notice will tell you about how we handle information about you. It tells how we use this information here in this office, how we share it with other professionals and organization, and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family. We are also required to tell you about this because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Because of this law and the laws of this state are very complicated and we don’t want to make you read a lot that may not apply to you, we have simplified some parts. If you have any questions or want to know more about anything in this Notice, please ask our Privacy Officer for more explanation or more details.

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Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can inspect, read, or review it. If you want a copy, we can make one for you but may charge you for the costs of copying (and mailing if you want it mailed to you). If you find anything in your records that you think is incorrect or something important is missing, you can ask us to amend (add information to) your record, although in some rare situations we don’t have to agree to do that. Our Privacy Officer, whose name is at the end of this Notice, can explain more about this.

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C. Privacy and the laws

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The HIPAA law requires us to keep you PHI private and to give you this notice of Privacy Practices, or NPP. We will obey the results of this notice as long as it is in effect, but if we change it the rules of the new NPP will apply to all the PHI we keep. If we change the NPP, we will post the new Notice in our office where everyone can see. You or anyone else can also get a copy from out Privacy Officer at any time.

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D. How your protective health information can be used and shared

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When your information is read by me or others in this office that is called, in law, “use.” If the information is shared with or sent to others outside this office, that is called, in law, “disclosure.” Except in some special circumstances, when we use your PHI here to disclose it to others we share only the minimum necessary PHI needed for the purpose. The law gives you the rights to know about your PHI and how it is used, and to have a say in how it is disclosed and so we will tell you more about what we do with your information.

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We use and disclose PHI for several reasons. Mainly, we will use and disclose (share) it for routine purposes and we will explain more about these below. For other uses, we must tell you about them and have a written Authorization from you, unless the law lets or requires us to make the use or disclosure without your authorization. However, the law also says that we are allowed to make some uses and disclosures without your consent or authorization.

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1. Uses and disclosures of PHI in healthcare with your consent

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After you have read this Notice will be asked to sign a separate Consent Form to allow us to use and share your PHI. IN almost all cases, we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrange for payment for our services, or some other business functions called health care operations. Together, these routine purposes are called TPO and the Consent form allows us to use and disclose your PHI for TPO. Re-read that last sentence until it is clear, because it is very important.

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1b. Other uses in healthcare

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Appointment Reminders. We may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or your work, or prefer some other way to reach you, we usually can arrange that. Just let us know.

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Treatment Alternatives. We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of interest to you.

 

Other Benefits and Services. We may use and disclose your PHI to tell you about health related benefits or services that may be of interest to you.

 

Research. We may use or share your information to do research to improve treatments. For example, comparing two treatments for the same disorder to see which works better or faster or costs less. In all cases your name, address, and other information that reveals who you are will be re\moved from the information give to researchers. If they need to know who you are, we will discuss the research project with you and you will have to sign a special Authorization Form before any information is shared.

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Business Associates. There are some jobs we hire other businesses to do for us. They are called our Business Associates in the law. Examples include a copy of service we use to make copies of your health record and a billing service who figures out, prints, and mails our bills. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they have agreed in their contract with us to safeguard your information.

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2. Uses and disclosures requiring your Authorization.

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If we want to use your information for any purpose besides the TPO or those we described above, we need your permission on an Authorization Form. We don’t expect to need this very often.

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If you do authorize use to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time we will not use or disclose your information for the purpose that we agreed to. Of course, we cannot take back any information we had already disclosed with your permission or that we had used in our office.

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2. Uses and disclosures of PHI from mental health records not requiring us to disclose PHI.

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* We have to report suspected child abuse

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D. If you have questions or problems.

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If you need more information or have questions about the privacy practices described above, please speak to the Privacy Officer whose name and telephone number are listed below. If you have a problem with how our PHI has been handled, or if you believe your privac7y rights have been violated, contact the privacy Officer. You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services. We promise that we will not in any way limit your care here or take any actions against you if you complain.

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If you have any questions regarding this notice or your health information privacy policies, please contact our Privacy Officer who is Dr. Mary J. Gunn, and can be reached by phone at (937) 276-3356.

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The effective date of this notice is April 14, 2003

INFORMED CONSENT FOR TREATMENT

I have read the information on my right of confidentiality and have been given a copy of the Notice of Privacy Practices. I agree and consent to participate in the psychological services offered and provided by CORDELL ASSOCIATES, LLC.

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​I understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the psychologist directly supervising the services received by the patient.

FINANCIAL AGREEMENT

I will pay my co-pay of $

​at the time of each visit as expected.

Initial

Initial

Any other arrangements need to be discussed and agreed upon with the office manager prior to or at the first appointment.

DIVORCED PARENTS

Initial

The parent requesting treatment in our office is responsible to pay the bill. Any co-pays or deductibles that need to reimbursed to you from the other parent are your responsibility to collect.

INSURANCE BILLING INFORMATION

CLIENT INFORMATION

Marital Status

PRIMARY RESIDENCE

SECONDARY INSURANCE INFORMATION

PLEASE SIGN AND DATE

NOTE: WE WILL NEED COPIES OF YOUR

PRIMARY/SECONDARY INSURANCE CARDS

CREDIT CARD EXPLANATION

To Our Clients:

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We have implemented a new policy for all telehealth appointments. If you have a co-pay/deductible you will be required to keep a credit card number on file. Your card will be charged the following business day of your appointment.

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This will be an advantage to you, since you will no longer have to call to make payments or mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out.

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This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

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If you have any questions about this payment method, do not hesitate to ask. This does not apply to clients currently receiving health benefits from any Medicaid or any Medicaid Managed Care plans.

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Sincerely,

Cordell Associates, LLC

CREDIT CARD EXPLANATION

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information

Card Type

I,

, authorize   Cordell Associates, LLC   to charge my credit card after each

therapy session. I understand that my information will be saved to file for future transactions on my account.

Thanks for submitting!

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