New Patient Registration Forms

I agree and consent to participation in the health care services offered and provided by Clearwave Mental Health, a health care facility. I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within (1) the scope of the license, certification, and training of the health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen {18) or unable to consent to treatment, I attest that I have legal custody of this individual and am legally authorized to initiate and consent to treatment on behalf of this individual.

You are responsible for all co-payments and/or fees at the time of service, otherwise billing fees will be Incurred. If another party is responsible for your payments, please let us know prior to your visit so that we may make the necessary arrangements.

A fee of $45.00 will be charged for any return checks, along with a processing fee.

Any cancellations and/or rescheduling of appointments must be done at least 48 hours in advance of your appointment to avoid any fees.

Patients who cancel and/or reschedule with less than 48 hours notice or do not show for their appointment will be responsible for the full self-pay rate (not just the co-pay rate).

Monday appointments must be canceled by noon of the preceding Friday.

**Appointment reminders/ confirmation calls are done as a courtesy**

I hearby authorize my insurance company to pay directly to Clearwave Mental Health all benefits due to me. This policy was in full force an effective at time of treatment. I understand that I am financially responsible for all balances remaining after payment of possible insurance benefits, and that, should it become necessary, any and all reasonable collections and attorney fees will be added to my bill. I also understand that my health information and records will be used, as needed, to obtain payment for my health care services from my insurance providers. This may include certain activities the Clearwave Mental Health staff may need to undertake before my health care insurer approves or pays for health care services recommended for me, such as determining eligibility of coverage for benefits, reviewing services provided to me for medical necessity, and undertaking utilization review activities.

I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it.

If you require legal, financial, or insurance forms to be completed by a Clearwave Mental Health clinician, it will need to be done in a scheduled session otherwise you will be charged and billed for the time that clinicians take to fill

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

I hereby authorize Clearwave Mental Health to keep my signature on file and charge the provided credit card for services rendered.

Background

A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to charge a patient more than a certain percentage in excess of the Medicare fee schedule amount. A new provision, which became effective on January 1, 1998, permits physicians and patients to enter into private arrangements through a written contract under which the patient may agree to pay the physician more than that which would be paid under the Medicare program.

A “private contract” is a contract between a Medicare beneficiary and a physician or other practitioner who has opted out of Medicare for two years for all covered items and services he/she furnishes to Medicare beneficiaries. In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician/practitioner and to pay the physician/practitioner without regard to any limits that would otherwise apply to what the physician/practitioner could charge. 

The purpose of this contract is to permit the patient (who is otherwise a Medicare beneficiary) and the physician to take advantage of this new provision in the Medicare law and sets forth the rights and obligations of each. This agreement is limited to the financial arrangement between Physician and Patient and is not intended to obligate either party to a specific course or duration of treatment.

Patients and physicians who take advantage of this provision are not permitted to submit claims or to expect payment for those services from Medicare. 

Exception:

In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the physician/ practitioner may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf. Payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner. 

A. Obligations of Physician
1.      Physician agrees to provide such treatment as may be mutually agreed upon by the parties and at mutually agreed upon fees.

2.      Physician agrees not to submit any claims under the Medicare program for any items or services even if such items or services are otherwise covered by Medicare.

3.      Physician acknowledges that (s)he will not execute this contract at a time when the patient is facing an emergency or urgent health care situation.

B. Obligations of Patient
1.      Patient or his/her legal authorized representative agrees not to submit a claim (or to request that the physician submit a claim) under the Medicare program for such items or services as physician may provide, even if such items or services are otherwise covered under the Medicare program.

2.      Patient or his/her legal authorized representative agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under the Medicare program for such items or services.

3.      Patient or his/her legal authorized representative acknowledges that that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.

4.      Patient acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to, make payments for items and services not paid for by Medicare.

5.      Patient acknowledges that (s)he has the right to obtain Medicare‐covered items and services from physicians and practitioners who have not opted out of Medicare, and that the (s)he is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out.

6.      Patient acknowledges that (s)he or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.

C. Physician’s Status
Patient further acknowledges his/her understanding that physician (has/ has not) been excluded from participation under the Medicare program under Section 1128.

D. Term and Termination
This agreement shall commence on the above date and shall continue in effect until two [2] years after [s]he signs the affidavit. Despite the term of the agreement, either party may choose to terminate treatment with reasonable notice to the other party. Notwithstanding this right to terminate treatment, both physician and patient agree that the obligation not to pursue Medicare reimbursement, for items and services provided under this contract, shall survive this contract.

I have read and understand the provisions regarding private contracting.

By signing this contract, I accept full responsibility for payment of the physician’s or practitioner’s charges for all services furnished to me from the date written above. 

The Patient and/or the Patient's legal representative:

• Accepts full responsibility for payment of Practitioner's charge(s) for all services furnished by the Practitioner.
• Understands that Medicare/Medicaid limits do not apply to what the Practitioner may charge for items or services furnished by the Practitioner.
• Agrees not to submit a claim to Medicare or Medicaid or to ask the Practitioner to submit a claim.
• Understands that Medicare or Medicaid insurance payment will not be made for any items or services furnished by the Practitioner that would have otherwise been covered by insurance if there was no private contract and a proper claim had been submitted.
• Enters into this contract with the knowledge that he/she has the right to obtain Medicare, Medicaid or other out-of-network insurance covered items and services from Practitioners who do accept Medicare, Medicaid and are in-network providers.
• Is not compelled to enter into this private contract that could be furnished by other Practitioners who accept Medicare, Medicaid and are in-network.
• Understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• Has not entered this private contract during a time when the Patient requires emergency care services or urgent care services.
• Acknowledges his/her understanding that the Practitioner has not been excluded from participation under the Medicare program under section 1128, 1156 or 1892 of the Social Security Act.
• Has signed this private contract prior to any services provided under the private contract's terms.
• Understands that either party may choose to terminate treatment with reasonable notice to the other party.
• Understands that the obligation not to pursue Medicare/Medicaid reimbursement for such items or services provided under this private contract shall survive this private contract.
• Agrees that this private contract shall be fully binding on the Parties' heirs and successors.
• Understands that a copy of this private contract will be provided at the request of the Patient and/or to his/her legal representative before items or services are furnished to the Patient under the terms of the private contract.
• Understands that this private contract will be retained (original signatures of both parties required) by the Practitioner for the duration of the private contract.
• Agrees that the Practitioner can supply CMS/Medicare/Medicaid with a copy of this private contract upon request.

I (“Patient”) have elected to receive ‘direct pay’ services provided by (“Practitioner”). I (“Patient”) understand that to receive these ‘direct pay’ services I am required to pay the fees for services at the time services are rendered.

Riverview Psychiatric Medicine, P.C. and TMS Medical of the Hudson Valley, P.C. are dedicated to ensuring the safety of our patients and staff. As such, we must ensure that all in-person appointments are done safely. To that end, our COVID-19 Safety Policy requires the following:

Patients should not attend in-person appointments if:

• They have recently tested positive for COVID-19;

• They have recently been in close-contact with someone who has recently tested positive for COVID-19; or

• They are feeling ill (including fever, persistent cough or fatigue)

In addition, masks or face shields must be worn during treatment and social distancing should be maintained whenever feasible.

Independent Contractor Physicians

 

Riverview Psychiatric Medicine, P.C. and TMS Medical of the Hudson Valley, PC (collectively, “Riverview”) contract with independent contractors to provide care to patients.  These independent contractors are not employees of Riverview and Riverview in no way directs, controls, or influences the care these independent contractors deliver to their patients.  Specifically, Riverview contracts with the following independent contractors:

 

Wilson Psychiatry P.C., which is owned and operated by Kenneth Wilson, MD;
Kimberly Robinson, M.D. Adult, Child and Adolescent Psychiatry, PLLC, which is owned and operated by Kimberly Robinson, MD; Maum Psychiatry which is owned and operated by Yesie Yoon MD;
Terri Coonrad-Hershkowitz Psychiatric Nurse Practitioner, P.C., which is owned and operated by Terri Coonrad-Hershkowitz, NP-P; and
Ellyn Enisman LCSW, LLC, which is owned and operated by Ellyn Enisman LCSW;
 

By signing below, you acknowledge that you understand that the above independent contractors who may provide you care are not employees of Riverview and that Riverview does not direct, control, or influence the care that they provide to you.