Dear New Client:
I am happy to file your insurance claim form for you monthly. To do that I need all your “insurance card” info. Plus your signature on the two statements below. Also, if you can please photocopy your insurance card front and back and bring with you. This will save time in your session.
Name of Insurance CO._____________________________
Name of the Insured Person (usually is the client, sometimes is client’s spouse or parent.): _________________________________________
Employer of Insured Person_________________________
Group Number:__________________________________ Who referred you to me/ how did you happen to call me?_______________________________
Your Address STREET ____________________________ CITY______________________ ZIP ___________________
Phone numbers: cell________________home:_____________
Insured person’s date of birth:__________________________
Client’s date of birth (if different):_____________________
Did you phone your insurance co. to ask about deductible, co-pay, and precertification?_______________
Patient’s Signature: I authorize the release of any information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
I authorize payment of benefits to Dr. Ellen Bierhorst
(continue to next page for important information and signatures required.)
[ ] Your Copy (save for your files) Ellen Bierhorst Ph.D.
[ ] My Copy Lloyd House 3901 Clifton Avenue
Cincinnati, OH 45220
(513) 221 1289
Your sessions are confidential. I will not disclose the fact of your being my client nor any information about you or your sessions with anyone without a written release signed by you (or for couples, by both partners). (Note that if you sign a release for your health insurance or managed care company to obtain clinical information about your care with me, then they have the right to demand any and all information about you. The privacy of records at insurance companies has been questioned.)
Exception to our confidentiality:
If I need to protect you or someone else from a clear and present danger of substantial risk of harm.
Also, I am required by law to report abuse of children or vulnerable adults to enforcement authorities.
The Ohio Revised Code of law, Section 4732.19 states that the relations and communications between a psychologist and client are placed under the same umbrella of privilege as those between physician and patient under division B of Section 2717.02. So as a psychologist, I can refuse even legal requests to share confidential information (unless you ask me to) except if the information was shared with me by you in the presence of a third party or if a court orders the information to be revealed. Certain information may also be revealed to insurance companies in relation to coverage issues or to defend a psychologist (i.e. myself) where allegations of misconduct are asserted. Children’s rights to confidentiality are also limited by the psychologist’s need to share with parents or others responsible for the good of the child.
The HIPPA rules on confidentiality are posted in my office and you may review them any time at your request.
It is my practice to email session notes to you, the client. These are not encrypted for security against hacking, or breech of security. You can choose to protect your privacy by never allowing me to send email to you, in which case you must remind me each session not to send the notes via email. I could print them for you on paper at the end of the session.
If you like, you can waive your right to ‘hacker-proof‘ emails from me by signing here:
_______________________________________________________ Date _______________________
I participate in peer supervision with other credentialed professionals and may present to such a team elements of your care. However, your name and all identifying information would be withheld to protect your privacy. If you would prefer that your work NOT EVER be the subject of peer supervision, please indicate that by telling me and by signing here:_____________________________________
Indicate that you have read and understood this page on confidentiality and security by signing and dating below:
(Your Signature)___________________________________________________ (date)_______________
PRINT YOUR NAME HERE:__________________________________________________________
My current regular fee is per 45 minute session. It is $125. If you have Anthem or Medicare insurance, you will need to check with them re. your co-pay. If you will be using your health insurance (any type) you need to phone them and ask if you need “pre-certification” to authorize the first number of sessions, typically ten. Ask also about your deductible so you will know what you will be paying for your sessions. Half sessions are charged half fee, a session and a half is one and a half fee, etc. The responsibility for your fee is yours, whether or not you have health insurance coverage, whether or not I submit your insurance claim for you. If you would like me to file claims monthly for you, please sign a release here:
I authorize the release of confidential information about my care to my insurance company if it is necessary to process claims for benefits. I also authorize my insurance company to send benefits checks directly to Dr. Bierhorst.
Anthem and some other companies typically give 5 – 12 sessions automatically, but after that you must prompt me to send in an “Outpatient Treatment Request Form”. Keep on top of this. If the number of authorized sessions runs out, you will have to pay the full fee out-of-pocket.
There will be a charge of $15 for a check returned to me by the bank for insufficient funds.
Payment for the session is due at the time of the visit.
Missed appointments are billed at the regular rate unless canceled 24 hours or more before the appointment time. You are responsible for the full fee, not just the co-pay for a missed appointment. (Insurance companies do not pay for missed appointments.)
Telephone consultations are billed if they exceed ten minutes in length. Ten to 35 minutes are billed as half a session
Bills outstanding for more than 90 days are subject to a finance charge of 1.5% per month. If a client fails to make payment on a balance due for six months, and has not contacted me or made arrangements for special circumstances, I reserve the right to turn their account over to a collections company.
In an emergency, you can attempt to reach me by phone. I do not carry a cell phone or pager. At night I tend not to answer my telephone after 8:00 pm. I have voice mail, and it is secure and confidential. If I do not answer, this messaging service will answer on the fourth ring. Also, if will answer immediately if I am using the telephone at the time. (To indicate to me that you have urgent need to talk with me, please call and leave a message, then call back immediately and ring only three times before hanging up. Repeat. If I am at home and hear the ring I will answer a repeated call no matter what the inconvenience.) If you are unable to reach me, you should call the telephone support service at 281-CARE or go to your nearest hospital emergency room.
If you leave me a message via voice mail, I may not be aware that you have done so for some time. Also, on rare instances, the Time-Warner voice messaging has lost messages. So please call back.
It is best to communicate scheduling issues via telephone RATHER than email.
I take notes during the session on my laptop computer. I print out a paper copy for you or, (preferably) will send the notes to you via email if you sign the written permission and give your email address. I keep the notes electronically on an indefinite basis as archives. If there is material you want to discuss without any written record being kept, please make sure I am aware of this. Your billing account also is kept indefinitely.
I have read and understood the above: ________________________________________(date)____________
Dr. Bierhorst may send confidential information to me via email.
I understand that no information sent via email is perfectly secure from ‘hacking’. I have told Dr. Bierhorst either to (check one)
- ___send my notes via email nonetheless OR
- ___ I have called to her attention the fact that I do not want her sending any material to me via email.
(email address, if you choose the first option) ___________________________________________________________