•   INTEGRAL HEALTH ASSOCIATES

  • New Patient Questionnaire

  • Please complete this form after scheduling an appointment. If you do not have an appointment yet, please call our office at (203) 909-6370 to schedule one before proceeding. 

    This form will take approximately 10-20 minutes to complete. 

    Please have your driver's license or other photo I.D. and your insurance card (or digital copies of these) at hand to complete the form. Thank you. 

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  • New Patient Questionnaire

    Please answer the following questions to the best of your ability. Information will be kept confidential. Enter N/A if not applicable.

  • Demographic Information

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  • Employment Information

  • Insurance Information

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for MAGELLAN PATIENTS

    Before your scheduled appointment, please call Magellan to obtain a prior authorization specifically to see {myAppointment}.  Confirm that the authorization is for a Managed Care session and not for the Employee Assistance Program (EAP).  It is very important to do this prior to your appointment in order to prevent your claim being denied.  Magellan will provide you with an authorization number that you can keep as a reference.  

  • Your provider is currently out-of-network with your insurance.  Please be aware that our services will be subjected to cash rates.  If you provide us your insurance information, we can submit claims upon receiving full payment for services rendered. Any out-of-network benefits will be sent directly to you from your insurance company.  Please follow up with your insurance company to make sure claims have been received and processed.  Thank you. 

  • Your provider may be out-of-network with your insurance and our services may be subjected to cash rates.  Please call our office or your insurance company to verify.  Thank you. 

  • Your provider is currently out-of-network with Medicare Advantage plans.  Please be aware that our services will be subjected to cash rates.  If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment.  Thank you. 

  • IMPORTANT NOTICE for MAGELLAN PATIENTS

    Before your scheduled appointment, please call Magellan to obtain a prior authorization specifically to see {myAppointment}.  Confirm that the authorization is for a Managed Care session and not for the Employee Assistance Program (EAP).  It is very important to do this prior to your appointment in order to prevent your claim being denied.  Magellan will provide you with an authorization number that you can keep as a reference.  

  • In Case of Emergency Contact

  • Other Healthcare Providers

  • Psychiatric History

  • Have you ever...

    (Please indicate Yes or No, and answer any follow-up questions)

  • Have you ever experienced...

    (Please choose the appropriate responses)

  • Are you currently experiencing any significant problems with...

  • Use of Substances

  • Have you ever used the following:

  • Medical History

  • 0/500

  • Medications

  • 0/500
  • 0/500
  • 0/200

  • Family History of Mental Illness or Substance Abuse

  • 0/500

  • Other

  • 0/250
  • 0/250
  • 0/500

  • Do you currently have substantial worries about your...

  • 0/500
  • 0/500
  • 0/500
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  • I, {name}, certify that the above information provided is true to the best of my knowledge.

    Signature of patient, parent, or legal guardian (Click on signature line):

    *   

  • Patient Authorization

  • AGREEMENT TO RECEIVE TREATMENT

    I, {name}, agree and consent to participate in behavioral health care services offered and provided by Integral Health Associates.

    Signature of patient (Click on signature line):

    *      

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    I, {name}, acknowledge that I have read the Notice of Privacy Practices of Integral Health Associates. Click here to view.

    Signature of patient (Click on signature line):

    *      

  • FINANCIAL RESPONSIBILITY

    I, {name}, hereby agree to pay all charges for services provided by Integral Health Associates for treatment. I agree to be personally responsible for such charges, including any fees associated for late cancellations, missed appointments, and late payments, including interest charges. Furthermore, I agree that if my account defaults because of my failure to pay the balance due, I will be financially responsible for the cost of payment collection, including collections agency and/or attorney fees and court costs permitted by law.   

    Signature of patient (Click on signature line):

    *      
      

  • RELEASE OF INFORMATION FOR INSURANCE PROCESSING
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I, {name}, hereby authorize Integral Health Associates to release medical information about me to my insurance company or managed care company for the purpose of documenting medical necessity and appropriateness of treatment, and for processing insurance claims.

    Signature of patient (Click on signature line):

             

  • AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I, {name}, hereby authorize my insurance company or managed care company to pay my health insurance benefits directly to Integral Health Associates for any treatment provided.

    Signature of patient (Click on signature line):

             

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  • The patient, {name}, is under the age of 18 or is unable to consent to treatment. I,   *   * , attest that I have legal custody of this individual and/or am legally authorized to initiate and consent to treatment on behalf of this individual.

    AGREEMENT TO RECEIVE TREATMENT

    I agree and consent for {name} to participate in behavioral health care services offered and provided by Integral Health Associates.

    Signature of parent or legal guardian (Click on signature line):

    *         

    ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge for {name} that I have been shown or given a copy of the Notice of Privacy Practices of Integral Health Associates. Click here to view.

    Signature of parent or legal guardian (Click on signature line):

    *         

  • FINANCIAL RESPONSIBILITY

    I hereby agree to pay all charges for services provided by Integral Health Associates for treatment. I agree to be personally responsible for such charges, including any fees associated for late cancellations, missed appointments, and late payments, including interest charges. Furthermore, I agree that if my account defaults because of my failure to pay the balance due, I will be financially responsible for the cost of payment collection, including collections agency and/or attorney fees and court costs permitted by law.   

    Signature of parent or legal guardian (Click on signature line):

    *            
       

  • RELEASE OF INFORMATION FOR INSURANCE PROCESSING
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I hereby authorize Integral Health Associates to release medical information for {name} to the appropriate insurance company or managed care company for the purpose of documenting medical necessity and appropriateness of treatment, and for processing insurance claims.

    Signature of parent or legal guardian (Click on signature line):

             

  • AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS
    (Please sign if you are using or plan to use insurance, otherwise leave blank.)

    I hereby authorize the insurance company or managed care company to pay health insurance benefits for {name} directly to Integral Health Associates for any treatment provided.

    Signature of parent or legal guardian (Click on signature line):

          

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  • Telehealth Consent

  • This consent and acknowledgment form covers the use of telehealth by Integral Health Associates.

    Within this document, “telehealth” includes communication forms such as telephone, cellular phone, and audiovideo that occur over information networks rather than in person. “Integral Health Associates” (herein referred to as “IHA”) includes the business entity known as such in the State of Connecticut and clinical providers contracted by the entity.

    I am indicating that I understand and am in agreement with the following:

    1. Engagement in telehealth by myself and IHA is completely voluntary. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. IHA has the right to offer or cease the offering of telehealth for any reason not specifically excluded by law.

    2. IHA will not disseminate any personally identifiable information obtained through the use of telehealth to other entities without my consent.

    3. Medical documentation of telehealth sessions by IHA will occur based on generally accepted standards, but Integral Health Associates will not voluntarily record or allow recordings of any part of any telehealth session. Likewise, I agree not to make or allow recordings of any part of any telehealth session.

  • 4. Despite reasonable efforts by IHA, there are risks and possible consequences from telehealth including, but not limited to, possible disruption of the transmission of my health information by technical failures, possible access and misuse of my health information by unauthorized persons, and the possibility that telehealth services may not be as complete or effective as face-to-face services.

    5. Services provided by IHA through telehealth services are professional services that may or may not be covered by insurance companies. IHA may be able to assist you with filing insurance claims, but ultimately, I am responsible for full payment just as I would be for face-to-face office visits.

    6. I agree to be available for telehealth sessions at the time of my appointments. This includes having the ringer on for telephone appointments, logging in for video appointments, and being in a quiet, private, distraction free location with reliable telephone, cellular, wifi, or ethernet connectivity as needed.

    7. Missed appointments will be charged the same as missed face-to-face sessions according to office policy. If I am available and my provider does not contact me within 15 minutes of a scheduled telehealth session, I am free to move on to other activity without being charged for a missed appointment.

  • 8. If a telehealth session is interrupted due to a technical problem, I agree to immediately make reasonable attempts to reconnect or contact my provider through some other means if available.

    I,{name}, hereby acknowledge my understanding of the above items, indicate my agreement to them, and consent to the use of telehealth as part of my overall treatment provided by Integral Health Associates.  

    Signature of patient (Click on signature line):

    *            

  • Signature of Parent or Legal Guardian if Patient is under 18 years old (Click on signature line):

    *            

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  • Magellan Health - Members' Rights and Responsibilities Statement

    Members have the right to:

    • Be treated with dignity and respect.
    • Be treated fairly, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.
    • Have their treatment and other member information kept confidential. Only where permitted by law may records be released without the member's permission. 
    • Easily access care in a timely fashion.
    • Know about their treatment choices. This is regardless of cost or coverage by their benefit plan.
    • Share in developing their plan of care.
    • Receive information in a language they can understand, and free of charge.
    • Receive a clear explanation of their condition and treatment options.
    • Receive information about Magellan, its providers, programs, services and role in the treatment process.
    • Receive information about clinical guidelines used in providing and managing their care.
    • Ask their provider about their work history and training.
    • Give input on the Members' Rights and Responsibilities policy.
    • Know about advocacy and community groups and prevention services.
    • If asked, Magellan will act on the member's behalf as an advocate.*
    • Freely file a complaint or appeal and to learn how to do so.
    • Know of their rights and responsibilities in the treatment process.
    • Request certain preferences in a provider.
    • Have provider decisions about their care made on the basis of treatment needs.
    • Receive information about Magellan's staff qualifications and any organization Magellan has contracted with to provide services.*
    • Decline participation or withdraw from programs and services.*
    • Know which staff members are responsible for managing their services and from whom to request a change in services.*

    Members have the responsibility to:

    • Treat those giving them care with dignity and respect.
    • Give providers and Magellan information that they need. This is so providers can deliver quality care and Magellan can deliver appropriate services.
    • Ask questions about their care. This is to help them understand their care.
    • Follow the treatment plan. The plan of care is to be agreed upon by the member and provider.
    • Follow the agreed upon medication plan.
    • Tell their provider and primary care physician about medication changes, including medications given to them by others.
    • Keep their appointments. Members should call their provider(s) as soon they know they need to cancel visits.
    • Let their provider know when the treatment plan is not working for them.
    • Let their provider know about problems with paying fees.
    • Report abuse and fraud.
    • Openly report concerns about the quality of care they receive.
    • Let Magellan and their provider know if they decide to withdraw from the program.*

  • * This standard is required for our Condition Care Management (CCM) products.

    My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.

    Signature of patient, parent or legal guardian (Click on signature line):

    *               

    The signature below shows that I have explained this statement to the patient. I have offered the member a copy of this form. 

    ________________________________
    Provider Signature

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  • I will provide a copy of my driver's license or other photo ID and a copy of both sides of my insurance card at least 7 business days prior to my scheduled appointment by:    
       
       
    *   
      
          

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  • Our preferred fax number for documents submission is (203) 777-6776. Our alternate fax number is (203) 909-6374.

    Our email address for submitting documents is forms@integralhealthct.com. Our email server is compliant with HIPAA, the federal regulation governing privacy of your healthcare information. Please be aware that your email account may not be HIPAA-compliant, and any documents that you submit to us by email may not be fully protected. If you have any concerns about the privacy of documents you are submitting by email, we advise you to use an alternate form of submission.

    Please click here to review our general policies. 

    When you are finished responding to the above questions, please click the submit button below.   

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