New Patient Questionnaire

INTEGRAL HEALTH ASSOCIATES
Insurance Update Form
Please have your insurance card (or digital copy of the card) at hand to complete the form. Thank you.
My current provider is:*
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Are you 18 years old or older?*
Do you currently have active medical insurance?

YesNo
Primary Insurance
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.
While your provider's status is "non-participating" Medicare may reimburse for a portion of services rendered. 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. Any benefits will be sent directly to you from Medicare. If you are unable to pay the full cash rate for services, please contact our office immediately to cancel your appointment. 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

If you have a new patient appointment scheduled, please call Magellan to obtain a prior authorization specifically to see {myCurrent}. 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.
Name of Insurance
Name of Employer
Full Name of Primary Person Insured
Policy (ID) Number
Plan Effective Date

MonthDayYear
Date
The primary insured person is my
Do you have secondary insurance?

YesNo
Secondary Insurance
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

If you have a new patient appointment scheduled, please call Magellan to obtain a prior authorization specifically to see {myCurrent}. 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.
Name of Insurance
Name of Employer
Full Name of Primary Person Insured
Policy (ID) Number
Plan Effective Date

MonthDayYear
Date
The primary insured person is my

Patient Authorization
RELEASE OF INFORMATION FOR INSURANCE PROCESSING

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):
Signature*
AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS

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):
Signature*
Date

MonthDayYear
Date
The patient, {name}, is under the age of 18 or is unable to consent to treatment. I, First Name* Last Name* , 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.
RELEASE OF INFORMATION FOR INSURANCE PROCESSING

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):
Signature*
AUTHORIZATION OF PAYMENT OF MEDICAL BENEFITS

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):
Signature*
Date

MonthDayYear
Date

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):
Signature*

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
Date

MonthDayYear
Date
Please provide a copy of your driver's license or other photo ID and a copy of both sides of your insurance card by uploading them using the button below.
To upload your photo ID and insurance card, click on button below:

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If you're unable to submit them now, please submit them using the online Document Submission Form on our website or via fax. Our preferred fax number is (203) 777-6776 and our alternate fax number is (203) 909-6374.

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

Patient Authorization