IMPORTANT INFORMATION FOR FILLING OUT ONLINE FORMS:

 

Please read these documents in their entirety.  It is imperative that you fill in all information requested to best serve your needs at Hampton Mental Health Associates (HMHA). 

There are numerous signatures required during this process.  Please understand that this is necessary to make sure that your electronic signature is on the proper pages of your chart in our office.  In addition, your name, address, and telephone numbers are requested several times as many of the forms are needed for different purposes in the office.  It is important that you fill them out whenever requested. If you have a Personal Representative such as a Healthcare Power of Attorney, Guardian or Court appointed Guardian, or if you are the parent, please indicate the person’s name where it asks for the name of the Personal Representative.

We hope you find your experience at HMHA an enjoyable one and that the needs that you are seeking solutions for are handled in the best way possible!

Thank you for visiting our online forms submission!

 

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.

Uses and Disclosures: We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Continuity of care is part of treatment and your records may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. We may use or disclose identifiable health information about you without your authorization in several situations, but beyond those situations, we will ask for your written authorization before using or disclosing any identifiable health information about you.

Your Rights: In most cases, you have the right to look at or get a copy of health information about you. If you request copies, we will charge you normal photocopy fees. You also have the right to receive a list of certain types of disclosures of your information that we made. If you believe that information in your record is incorrect, you have the right to request that we correct the existing information.

Our legal duty: We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice, and seek your acknowledgement of receipt of this notice. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area.

You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services.

If you have any questions or complaints, please contact:

Trina Ruple 2112 Hartford Rd Hampton, VA 23666 (757) 826-7516

Uses and disclosures of Protected Health Information

Following are examples of the types of uses and disclosures of your protected health care information that the provider is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. For example, your protected health information may be provided to a doctor to whom you have been referred to ensure that the doctor has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, in activities related to obtaining payment for your healthcare services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to your health insurance company to obtain approval for the admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support our business activities. For example, when we review employee performance, we may need to look at what an employee has documented in your medical record.

Business Associates: We will share your protected health information with third party business associates that perform various activities (e.g. billing, transcription services Whenever an arrangement between us and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Marketing: We may use or disclose certain health information in the course of providing you with information about treatment alternatives or health related services. You may contact us to request that these materials not be sent to you.

Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing.

Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to object. If you are not present or able to object, then your provider may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, and your condition (in general terms).

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person=s involvement in your healthcare.

Emergencies: In an emergency treatment situation, your provider shall try to provide you a Notice of Privacy Practices as soon as reasonably possible after treatment is provided.

Communication Barriers: We may use and disclose your protected health information if your provider attempts to obtain acknowledgement from you of the Notice of Privacy Practices but is unable to do so due to substantial communication barriers and the provider determines, using professional judgment that you would agree.

Without Opportunity to Object

We may use or disclose your protected health information in the following situations without your authorization or opportunity to object:

Public Health: for public health purposes to a public health authority or to a person who is at risk of contracting or spreading your disease.

Health Oversight: to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

Abuse or Neglect: to an appropriate authority to report child abuse or neglect, if we believe that you have been a victim of abuse, neglect, or domestic violence. Food and Drug Administration: as required by the Food and Drug Administration to track products.

Legal Proceedings: in the course of legal proceedings.

Law Enforcement: for law enforcement purposes, such as pertaining to victims of a crime or to prevent a crime.

Coroners, Funeral Directors, and Organ Donation: for the coroner, medical examiner, or funeral director to perform duties authorized by law and for organ donation purposes.

Research: to researchers when their research has been approved by an Institutional Review Board.

Soldiers, Inmates, and National Security: to military supervisors of Armed Forces personnel or to custodians of inmates, as necessary. Preserving national security may also necessitate sharing protected health information.

Workers Compensation: to comply with workers compensation laws.

Compliance: to the Department of Health and Human Services to investigate our compliance.

In general, we may use or disclose your protected health information as required by law and limited to the relevant requirements of the law.

Your Rights

You have the right to:

Inspect and copy your protected health information.   However, we may refuse to provide access to certain psychotherapy notes or information for a civil or criminal proceeding.

Request a restriction of your protected health information. You may ask us to use or disclose certain parts of your protected  health information for treatment, payment or healthcare operations. You may also request that information not be disclosed to family members or friends who may be involved in your care.

Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, but if we do agree, than we must behave accordingly.

Request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation as to the basis for the request.

Ask your provider to amend your protected health information. You may request an amendment of protected health information about you. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and your medical record will the note the disputed information.

Receive an accounting of certain disclosures we may have made.

This right applies to disclosures for purposes other than treatment, payment or healthcare operations. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations.

Obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

By signing this document, you acknowledge receipt of this information and your understanding of the information contained herein. Should you fail to submit this document to us, you will be asked to sign acknowledgment of receipt at check in at an in office appointment.  Your signature below attests that you are the patient's Personal Representative (parent, guardian, stepparent, foster parent) signing this form:

FINANCIAL POLICY - WEBFORM

Thank you for choosing us as your health care provider. We are committed to your health treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require that you read, and sign prior to any treatment.

ALL patients must complete our Information and Insurance form before seeing the doctor or therapist.

*******FULL PAYMENT IS DUE AT THE TIME OF SERVICE******

****We accept Cash, Checks, or Visa/MasterCard******

Regarding Insurance:

We may accept assignment of insurance benefits. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us correct insurance information and original identification card (copy). Please be aware that some, or perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or medical insurance. If we are not a participating provider, we are not a party to that contract, so unpaid balances will be your responsibility.

Regarding Insurance Plans where we are a participating provider:

All co-pays and deductibles are due prior treatment. In the event that your insurance coverage changes to a plan where we are not a participating provider refer to the above paragraph.

Usual and Customary Rates:

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Regarding Records Request:

For Medical Records Requests, the minimum fee is $15.00, which incorporates a $10.00 handling fee and the first 5 pages, then it is .50 per page for every additional page up to 50 pages and .25 per page for all additional pages thereafter. Medical Records take 7-14 days to process. If a request is made to transfer records to a new provider, the fee is waived. There is a $15-$25 fee for any forms that need to be filled out by a doctor or therapist (i.e. DMV, Insurance, Disability, ETC.)

Missed Appointments:

Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $50.00. Please help us serve you better by keeping scheduled appointments.

Thank you for understanding our Financial Policy. Please let us know your questions or concerns. HMHA reserves the right to increase the amount charged for returned checks, missed appointments, and medical records requests. Your signature below agrees to these terms. Your signature below indicates that you have read the Financial Policy. You understand and agree to this Financial Policy and agree that if your insurance company requires Pre-Authorization before treatment and you fail to comply you will be responsible for the charges incurred.

My signature below attests that I am the the patient's Personal Representative signing this form

 

HMHA’s therapists and physicians will not participate in any custody cases or any case that requires a court appearance. Should any lawyer of our patients or any other lawyer subpoena our therapist/physicians, our fee for appearing in court is $2,500, paid in advance.

Should the fee not be paid in advance, HMHA will take legal action to recover the fee plus any accrued court costs.

Thank you for understanding our Court Custody Policy. You will be asked to sign a Consent for Treatment and Certification of Obligation for Payment of Balances Due form attesting that you have reviewed and understand the information contained in this document. Your signature on that form indicates your understanding of this policy and that you agree to its financial terms.

My signature below indicates that I am the patient or legal representative signing this form.

CONSENT: I hereby request and consent to medical and/or diagnostic treatment by Hampton Mental Health Associates, Inc. (HMHA) and hereby authorize physicians, nurse practitioners, and therapists to treat me or minor(s) in my legal custody, including stepchildren, in ways they determine to be therapeutically necessary. I understand that this treatment may include tests (lab/diagnostics), examinations, and administration of medications. I understand that during treatment, the possibility exists for health care workers to become directly exposed to the individual’s blood or body fluids. Virginia law authorizes health care providers to test patients for HIV and hepatitis B & C antibodies when a health care provider or any person employed by or under the direction and control of a health care provider is exposed to the body fluids of a patient on the basis of deemed consent. In the event of exposure, I understand that I will be deemed to have consented to testing, and consent to release test results to the health care worker who may have been exposed. Prior to testing, I will be informed and given an opportunity to ask questions. I consent to the release of prescription history from any drug pharmacy or drug monitoring agency to my physician or healthcare provider.

PAYMENT OBLIGATION/BALANCES DUE: I irrevocably direct and assign payment from my insurance company, Medicaid, Medicare, Tricare, or other provider of health care benefits to HMHA for services rendered. I understand that my insurance policy is a contract between my insurance company and me, and that I am responsible to HMHA for any charges not covered by my insurance, including co-payments, deductibles, and fees for non-covered services. If all charges are not paid when due to HMHA, the undersigned agrees to pay all costs of collection, including collection agency fees.

Once payment has been received from my insurance company, any balance remaining on my account will be payable by me at the time of my next appointment. Co-payments and deductibles are due prior to treatment. I have been informed that a fee of $35 may be applied to my account for any returned checks and a $50 fee for missed appointments not canceled at least 24 hours in advance. RETURNED CHECK FEE is only payable in cash or by money order. For Medical Records Requests, the minimum fee is $15.00, which incorporates a $10.00 handling fee and the first 5 pages, then it is .50 per page for every additional page up to 50 pages and .25 per page for all additional pages thereafter. Medical Records take 7-14 days to process. Records take 7-14 days to process Forms filled by provider fee is $15 $25. HMHA reserves the right to increase the amount charged for returned checks, missed appointments, and medical records requests. Your signature below agrees to these terms. Please direct all billing inquiries to the HMHA Billing Representative.

• I have been given an opportunity to review the “ Patient Financial Policy ” and my signature certifies that I agree with its terms.
• I have reviewed and unders tand the “ Court Custody Statement ” and its financial terms.

 I certify that I have read this form in its entirety and I understand the contents of this form and that I am the patient or the patient’s parent/legal guardian and have the authority to request this treatment. Furthermore, I permit a copy of this document to be used in place of the original. I certify that all statements are true and correct and I understand that false statements or documents or concealment of a material fact may be prosecuted under federal or state laws. My signature below attests that I am the patient's Personal Representative and my understanding of this form, my agreement with, and my consent.

 

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life-threatening illness and even death. Hampton Mental Health Associates cannot prevent you or your child(ren) from becoming exposed to, contracting, or spreading COVID-19 while utilizing Hampton Mental Health Associates’ services or premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to utilize Hampton Mental Health Associates’ services and/or enter onto Hampton Mental Health Associates’ premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID 19.

ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself and/or my children in order to utilize Hampton Mental Health Associates’ services and premises. These services are of such value to me and/or to my children, that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to utilize Hampton Mental Health Associates’ services and premises in person rather than arranging for an alternative method of enjoying the same services virtually (e.g. videoconference

WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against Hampton Mental Health Associates’ and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing Hampton Mental Health Associates’ services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.

CHOICE OF LAW: I understand and agree that the law of the State of Virginia will apply to this contract.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE:

My signature below indicates that I am the patient or parent/legal representative signing this form:

 

My signature below attests that I am the patient or the patient’s legal representative.

PERSON RESPONSIBLE FOR CARE OF PATIENT IF MINOR

I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits to which I am entitled from any insurance plan to Hampton Mental Health Associates. Please remember that insurance is a method of reimbursing the patient for services/fees paid to Hampton Mental Health Associates and is not a substitute for payment. It is your responsibility to pay any deductible, coinsurance or any other balance not paid by your insurance within a 90 day period. Please sign below to acknowledge your agreement to these terms. I understand that should I miss my appointment without notifying the office prior to 24 business hours, I will be charged $50.00. Please notify the office ifyou do not wish to be contacted at home or work.

TERMS AND CONDITIONS:

1.  I hereby authorize Hampton Mental Health Associates to use the telehealth practice platform for      telecommunication for evaluating, testing, diagnosing and treatment of my mental health condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I understand that I am to observe telehealth etiquette during my appointment with my provider to include the following:

• On WIFI connection (not data/cell service)
• Have Zoom already downloaded, if you are unsure how to do this please      contact the front desk
• Be seated in a private, quiet, well-lit location. Please do not attempt to have your appointment in a public space. If this occurs, your provider may ask that you reschedule your appointment for a different time.
• Sign into the meeting 5-10 minutes prior to your appointment time. Your provider may be a few minutes behind, but they will be with you shortly.
• Be appropriately dressed and sitting. Treat this appointment as if you were coming into the office.
• Make sure your video camera, microphone AND speaker are turned on

4. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met. I understand that in the future, the voice communications may not be allowed depending on the rules of Medicaid, Medicare, and commercial insurance companies and at that time, I will be required to participate in teleconference calls or come into the office for an in person visit. 

5. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

6. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

 

My signature below attests that I am the pateint or the patient's personal representative signing this form and my agreement with the terms and conditions.

Should you wish to decline to designate someone to speak with medical staff or administrative staff on your behalf, after filling in the patient's name and/or patient's personal representive, please scroll down to the last section "I decline" to make that selection.

The following person(s) are given permission to speak to a physician, nurse practitioner, or other administrative staff at Hampton Mental Health Associates, Inc., should it be necessary, on my behalf.  I hereby give permission for Hampton Mental Health Associates, Inc. through its physicians, nurse practitioners, and administrative staff to release to my designee(s) any information about my medical condition or medical needs or the status of my account and I release Hampton Mental Health Associates, Inc., it’s physicians, nurse practitioners, and administrative staff, from any claim of confidentiality in connection with the release of this information. 

Persons to whom we may release information:

I designate the above individuals to speak with medical staff (physician or nurse practitioner) or administrative staff concerning my health information and account.  My signature below attests that I am the patient or the patient’s Personal Representative signing this form electronically.

I decline to designate another person to speak with medical staff (physician or nurse practitioner) or administrative staff.  My signature below attests that I am the patient or the patient’s Personal Representative signing this form electronically.