* Enter N/A if you are self/cash pay patient

* Enter N/A if you are self/cash pay patient

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Summit Behavioral Health may not contract with all commercial insurance carriers and may be an "out of network" provider for these insurance carriers and health benefit pians. Please check with your carrier or benefit plan because your out-of -network payment responsibility may be higher than an in-network option. The undersigned agrees, whether she/he signs as agent or a patient, that in consideration of the services to be rendered to patient, she/he hereby is responsible for paying facility copayments, deductibles, estimated facility coinsurance amounts, and any balance deemed to be a covered benefit of the insurance policy. Monthly statements will be sent to guarantors for patient balances. Acceptable means of payment are cash, money order, cashiers check, credit card, or personal check.

ADDITIONAL BILLS: By signing this form, I acknowledge that physicians or health care providers providing services to me while at Summit Behavioral health may bill me separately from Summit Behavioral health. I understand that physicians or health care providers providing services to me while at Summit Behavioral health may not be a participating provider with the same commercial insurance carriers or benefit plans as Summit Behavioral health. For example, my admitting physician, emergency room physicians, pathologists, radiologists, anesthesiologists, hospitalists, and others may bill me separately from Summit Behavioral health for the amount unpaid by my health plan, if any. I understand that I am responsible for paying all providers subject to the terms of my health plan or insurance, if any.

ASSIGNMENT OF INSURANCE BENEFITS & AUTHORIZATON TO RELEASE INFORMATION Summit Behavioral health may not contract with all commercial insurance carriers, and may be an "out of network" provider. I understand that Summit Behavioral health will verify my benefits, collect a portion of my responsibility (i.e. co-pay, deductible and/or co-insurance) at the time of service and bill my insurance provider for the services benefits. I further understand that if any of the services or charges are not covered by my insurance company/benefit plan or Summit Behavioral health is unable to verify eligibility, I am responsible for all charges incurred for services rendered. I hereby assign and transfer to Summit Behavioral health all right, title, and interest in any and all health insurance and/or health plan proceeds/benefits from any of my plans(s) arising from the provision of any goods and services provided by Summit Behavioral health and/or any physicians/healthcare providers thereof. I also hereby assign and transfer to Summit Behavioral health all right, title and interest in any claims against any health insurers, sponsors and/or plan administrators of any of my health benefit plan(s) arising from or pertaining to any wrongful acts and/or omissions pertaining to any of said health/benefit plan(s) or health insurance policy(ies), including but not limited to claims for the non-payment or underpayment of health provider invoices and claims. I further expressly and knowingly assign all rights under my benefit plan the Employee Retirement income Security Act of 1974 to sue my benefit plan for any breach of its fiduciary duty. By executing this assignment of .benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employer, employer group, or trust sponsored or offered plan) to pay the Facility and/or Facility-based physicians (Facility-based physicians include, but are not limited to: Emergency Department Physicians, Hospitalists, Pathologists, Radiologists, and Anesthesiologists). Summit Behavioral health files primary and secondary insurance claims for insured patients. I authorize the facility and/or physicians indicated above to release medical information about me as may be necessary for the completion of my insurance claims for this occasion of service to any insurance carrier, health or hospital plan.

MEDICARE PAYMENTS: (Patient's Certification, Authorization to Release Information, and Payment Request) I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf.

OUT OF STATE MEDICAID: Summit Behavioral health is not enrolled with any out of state Medicaid plans. By signing this form, I acknowledge that I will be responsible for charges if reimbursement is not available through my Medicaid provider.

The undersigned certifies that she/he is the patient or is duly authorized by the patient as the patient's general agent to execute the above and accepts its terms.

WHAT ARE YOUR PRIMARY CONCERN(S) AND WHAT IS THE DURATION OF THESE CONCERNS?

PSYCHIATRIC SYMPTOMS

DEVELOPMENTAL HISTORY

FAMILY PSYCHIATRIC HISTORY

SOCIAL HISTORY

PAST MEDICAL HISTORY

FOR FEMALE PATIENTS ONLY:

MEDICATIONS

Please list all current medications and dosage including over the counter medications and supplements:

TELEPHONE COMMUNICATION PREFERENCES

MAIL COMMUNICATION PREFERENCES

Other Communication - Other than you, your insurance carrier, and health care providers involved in your care, who we talk about your health care information?

• I acknowledge that I have been given the opportunity to request restrictions on use and/or disclosure of my protected health information
• I acknowledge that I have been given the opportunity to request alternative means of communication of my protected health information
• I acknowledge should I change my mind I have the right to revoke all active authorizations on file by completing a Revocation of Authorization to Release Protected Health Information

FILL THE FOLLOWING FORM IF YOU ARE SWITCHING TO US FROM OTHER MENTAL HEALTH PROVIDERS

I UNDERSTAND I MAY REVOKE THIS AUTHORIZATION AT ANY TIME TO THE ADDRESS LISTED AT THE TOP OF THIS FORM. I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO INFORMATION THAT HAS ALREADY BEEN RELEASED IN RESPONSE TO THIS AUTHORIZATION. I UNDERSTAND THAT TREATMENT MAY NOT BE CONDITIONED ON MY AGREEMENT TO SIGN THIS AUTHORIZATION.THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE ONE YEAR FROM THE DATE OF MY SIGNATURE. I UNDERSTAND THAT ONCE INFORMATION IS RELEASED PURSUANT TO THIS AUTHORIZATION WE CANNOT PREVENT THE REDISCLOSURE TO ANOTHER THIRD PARTY. A COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS VALID AS THE ORIGINAL.