IHCC Admission Packet

IHCC Intake Packet

Psychological Testing, Mental Health Services, Med Management
Thank you for choosing Innovative Health Care Concepts.

This admission packet is comprised of the following sections:
1. Patient Demographic Information
2. Payment and Insurance Information
3. Primary Care Practioner Notice (if applicable)
4. Psychological Testing Sections (if applicable)
5. Patient Medical Questionaire (if applicable)
6. Patient History Questionaire (if applicable)
7. Acknowledgement of Terms and Conditions of Service
8. Signature and form Submission
9. PSC-35 (ages 3-17 only)
10. WHODAS 2.0 (if applicable)
11. PHQ-9 (ages 12 and older)
12. GAD-7 (ages 12 and older)
Which sections you will need to fill out will depend on the services you are seeking. All applicable sections must be completed prior to submission of the packet. If you provide an email address you will receive an email confirmation upon submission, however, for your privacy, none of the information entered will be sent in that email. You may request a copy of your admission packet at your appointment. If after submitting this packet you need to change or correct any of the information submitted, you may do so by following the corresponding link in your submission confirmation email.

We do not recommend filling out this form on a phone. For a better experience please use a desktop, laptop, or large format tablet.

For individuals seeking services that are 14+ years old, it is encouraged that they independently complete as much of the admission packet possible, as appropriate.
Important Disclosure

We take your personal information very seriously. This form collects your personal information in order for us to evaluate your needs and schedule an appointment with the appropriate doctor or counselor. This form uses an encrypted secure connection and all data is stored in strict compliance with current HIPAA standards and can only be accessed by the authorized members of our team.

Your browser remembers your information as you enter it until you submit the form or close the browser window, at which point all the information is cleared from the browser. Please be aware that if you close the browser window prior to submitting the form, all information entered will be lost. If you are using a public computer we strongly suggest that you complete and submit the form in a single sitting, or close the browser window, before leaving the computer.

You do have the option at any time to save the form and continue filling it out later, even after closing the browser window. To do so click the 'Save' button at the bottom of any page. We use Jotform as our forms partner and you will need to create an account with Jotform in order to use that service. IHCC has no access to an account you set up with Jotform and is not responsible for anything related to that account.

Please review our privacy policy to see how we manage your submitted data.
Acknowledgement*

I have reviewed the privacy policy and agree to my data being collected.

Policy Regarding Unsupervised Minor Participants

Please read the Policy and acknowledge the box below
Acknowledgement of Policy Regarding Unsupervised Minor Participants

There are times when a parent and/or guardian will allow their child or ward, to be unsupervised in our waiting areas. For example, a child is receiving testing services for an extended period of time (i.e. 2-3 hours) and the parent does not want to stay in our building for the duration of the appointment. IHCC understands the need to leave the participant in our facility, however, we do require parents or legal guardians to give written consent releasing IHCC from any liability if the participant refuses to participate in testing, leaves the building, exhibits significant maladaptive behavior, or is harmful to themselves or others. The following protocol will be followed in the event a participant is left alone in our facility:

• The parent/guardian will be educated on our policy regarding leaving their child or ward in our facility without parental or responsible party supervision and asked to sign an acknowledgement of understanding. A responsible party is defined as an individual the parent or guardian has assigned the care of their child or ward to, such as a Grandparent, adult sibling, friend, Direct Care Provider, etc.

• In the event a participant exhibits maladaptive behavior such as refusing to participate in testing or disruptive behavior, we reserve the right to discontinue testing and the parent/responsible adult must be available by phone to come and pick up the participant if necessary, or remain with the participant to reduce maladaptive behaviors

• In the event the participant exhibits self-harming behavior or behavior that is harmful to others, IHCC reserves the right to contact the authorities for support and assistance. The parent/responsible party will also be contacted and must be available by phone. If the participant is actively engaging in harming behavior that is injurious to self or others, IHCC staff may need to physically intervene solely for the purpose of prevention of harm and protection of the participant and others until authorities arrive. All attempts to deescalate the child will be made and any physical contact between IHCC personnel and participant will be done solely for the purpose of safety and only by individuals trained in crisis prevention.

• In the event the participant leaves the building, IHCC will contact the police and the parent/responsible party immediately. The parent/responsible party must be available by phone. IHCC may follow the participant to ensure safety either by foot or vehicle if this is felt to be necessary, but will not be held responsible for the participant’s actions or safety out in the community. IHCC will not physically engage with a participant in order to force them to return to our facility. If there are any concerns of elopement, a parent or responsible party should not leave the participant without supervision in our facility.

• If a participant exhibits any of the above behaviors or safety concerns at any time, or if we have had to contact the parent or responsible party to ensure the safety of the participant, the participant will no longer be allowed to receive services without a parent or responsible party present at all times.

My acknowledgement signifies that I have read and understand IHCC’s policy on leaving my child or ward unsupervised in IHCC’s facility, either at The Testing Center or the Integrated Services Center. I understand that if I choose to leave my child or ward before, during, or after their appointment that I will not hold IHCC liable if my child or ward exhibits maladaptive behavior, harmful behavior to self or others, or elopes from the building. I understand that IHCC staff and clinicians are not providing child care services, but rather a clinical, or medical treatment or evaluation and that by leaving my child or ward, I am choosing to leave them unsupervised. If I choose to leave, my actions will be seen as confirmation that my child or ward does not participate in maladaptive behavior, harmful behavior to self or others, or elopement, and I am not concerned about their safety or the safety of others in my absence. I further understand that if I choose to leave, I will be available by phone, will answer my phone if called, and agree to come back upon request without delay. I also agree to pick my child or ward up at the designated time and understand that this is not a child care facility and that my child or ward will be unsupervised in the waiting areas if I am not present.

Download the Unsupervised Minor Participant policy.
Acknowledgement*

I have read the Unsupervised Minor Participant Policy and agree to its terms.
Not a Minor Child
Are there any issues regarding child custody we should be aware of?*

YesNo

Parent Conflict Disclosure

Please read the statement and acknowledge the box below
In the event a child is referred for services and there is conflict present between both biological parents, especially in cases of divorce, pending divorce, marital conflict, or separation, the parent who initiates the request for services and attends the intake appointment will be responsible to disclose to the other parent or legal guardian about the services and the opportunity to complete applicable parent forms and provide feedback regarding the child. Please understand it is not the responsibility of Innovative Health Care and/or it’s providers to mediate conflict regarding the child’s services between conflicting parents. If the parent not present at the intake appointment wishes to provide feedback typically obtained at the intake appointment, they may call to schedule a separate appointment with the provider. For Testing services, if parents wish to complete separate parent forms due to conflicting views, an additional set of parent forms may be provided upon request for the second parent at a cost of $4.00 per booklet. If parents would like to meet separately to review results and discuss recommendations, we can accommodate this. It is the responsibility of the parent to contact us in order to receive these accommodations. In the event a parent would like us to deny access to another biological parent, we must have a court order on file ordering this action.

Download the Parent Conflict Disclosure statement
Acknowledgement*

I have read and agree with the Parent Conflict Disclosure statement and understand my obligations.
Conflict is No
Conflict not minor

Primary Care Practitioner Notice

Primary Care Practitioner Release of Information
Innovative Health Care's Integrated Services is my Primary Care Practitioner*

YesNo
Physician Notice and Release for Mental Health:

Please tell us if we may or may not give notice to your Primary Care Practitioner that you are receiving mental health services.

Note: If you select 'yes', on the next page you will be asked to complete a Release of Information form unless we are your Primary Care Practitioner.
Coordination of Care:

Please tell us if we may or may not contact your previous primary care practioner in order to coordinate care.

Note: If you select 'yes', then on the next page you will be asked to complete a Release of Information form.
May we contact your previous PCP to coordinate care?*

YesNo
May we inform your Primary Care Practitioner that you are receiving mental health services?*

YesNo
Physician Notice and Release for Testing:
Most insurance plans request that your primary care physician be notified if their patient is being seen for testing. By checking “Yes” below, you are authorizing us to send your completed evaluation to your Primary Care Physician.
May we send the completed evaluation to your Primary Care Physician?*

Yes, you may send the completed evaluation to the Primary Care Provider.No, you may NOT send the completed evaluation to the Primary Care Provider.
Note: If you select 'yes', on the next page you will be asked to complete a Release of Information form unless we are your Primary Care Practitioner.
ROI Calculation

Terms and Conditions of Service

Review and Acknowledge
Authorizations, disclosures, and the terms and conditions for service. Click on each section title to review and acknowledge that you have read and understand it's contents. All sections must be acknowledged prior to form submission.

Psychological Testing Acknowledgements
Service Extender Use

I understand and agree that a professional with a minimum of a Master’s Degree serving as a Service Extender under a neuropsychologist or psychologist licensed in the State of Idaho may be involved in my care. This individual may provide services at Intake and in the completion of neuropsychological or psychological test administration. I understand that the Service Extender is not responsible for interpretation, diagnosis, or reporting and that these services will only be provided by the licensed Psychologist or Neuropsychologist.

Our current service extenders are Nancy Boyce, Patricia Marnell, Lisa Kunz, and Dana Rankin. Our counseling service extender is Dr. Ashley Wasilewski.
Statement of Distribution Charges

We will distribute your evaluation via fax to anyone indicated in the "Distribution of Evaluation" section of this form free of charge. We will provide a copy to the patient's Primary Care Physician, if you checked "Yes" in the "Physician Notice and Release" section of this form free of charge. We will provide via pick up, regular mail or our secure email messaging system, an original evaluation to the responsible party free of charge. Any additional hard copies requested will be charged a fee of $2.00 per evaluation and available for you to pick up. If you would like additional hard copies mailed, a charge of $3.00 per evaluation will be charged and mailed upon payment. For all evaluations, we must have a signed Release of Information for the receiving party or they must be listed on the Distribution List. Credit and Debit card payments may be made over the phone.
Pre-Service Charges

Please note an evaluation consists of three types of appointments: Intake, Testing, and Feedback. The testing portion may take several different appointments to complete. Once you have completed your Intake Appointment, the doctor will spend time evaluating your information in order to determine the tests that need to be administered. This will result in identifying how many hours the patient will need to schedule for testing. This is a billable activity. If you choose not to pursue testing, you may be charged for the time the doctor spends on pre-service evaluation. This will not exceed one hour of billable time.
Acknowledgement*

I agree to the Psychological Testing Acknowledgements Terms and Conditions

Transportation for Community Services
Overview of Transportation for Community Services
Transportation of participants may be necessary during the delivery of community based services such as Skills Building, Peer/Youth Support, Respite, etc. IHCC staff are allowed to transport participants in their own personal vehicles for the purpose of work-related activities. This may include transportation to community-based activities, such as medical appointments as applicable, and to and from pick up locations such as school, home, other therapies, etc. as discussed with the participants parent/guardian. IHCC staff are able to transport participants in their personal vehicles as long as the following rules have been met: The staff maintain a current driver’s license, current vehicle registration, and current auto insurance policy. These documents will be maintained in the staff’s personal file at all times. Prior to any transportation of participants, the staff must reasonably be able to verify that the vehicle is safe, reasonably clean, free of hazards, and has working seatbelts. The transporting staff must also maintain the ability to adhere to all laws, rules and regulations applicable to drivers by maintaining a clean driving record.

When appropriate, a car seat will be utilized according to national guidelines for children’s car safety. It is the participant’s parent/guardian responsibility to provide a children’s car seat for the purpose of transportation when necessary.

I acknowledge that transportation may be provided during the delivery of community services and consent to the IHCC staff providing transportation as agreed upon with parent/guardian.

Download a copy of the Transportation for Community Services Consent form (PDF document).
Acknowledgement*

I have read, fully understand, agree with and consent to the Transportation for Community Services conditions.

Payment of Services
Insurance, including Medicaid, provides for your reimbursement on allowed medical charges. As a courtesy to you we will provide an itemized statement you may send to your insurance company for payment. We will be happy to submit to most insurance carriers, if you have provided us with policy numbers, address, place of employment, and any other pertinent information. You are responsible for all deductibles and charges not covered by insurance. Payment options may be reviewed with you prior to services. Please understand that we cannot, as a third party, become involved in prolonged insurance negotiations, this is your responsibility. All accounts with an outstanding balance over 120 days or more will be subject to collections. In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all costs charged by the collection company, which costs will not exceed 20% of said unpaid balance, including a reasonable attorney’s fee. I authorize the release of any medical information necessary to process any claim. I permit a copy of the authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.
Acknowledgement*

I agree to the Payment of Services Terms and Conditions

Medical Consent
I consent to the services which may be performed as a patient, on an outpatient basis, within the scope of practice authorized under the licenses of the respective licensed providers. For purposes of this agreement, the term, “Medical” shall refer also to psychological, neuropsychological, mental health, or behavioral services. If I am participating in testing services, I understand the patient will be tested using standardized testing tools to assess cognitive, adaptive, and behavioral functioning. A list of possible testing procedures will be provided upon request. I understand that if the patient has a history of Autism Spectrum Disorder (PDD-NOS, Asperger’s Disorder, Autistic Disorder), testing for Autism Spectrum may be recommended. This may include the ADOS-2 and/or GARS as part of the battery of tests that will be performed. I understand that some clinicians provide services under contract with Innovative Health Care Concepts, Inc. (IHCC), and IHCC is responsible for support services and the collection of fees for rendered services. IHCC will be seeking reimbursement for services from Medicaid, Medicare, Insurance benefits for which providers may be eligible, and/or responsible parties. I certify that the information given or will be given by me or upon my behalf is true, correct, and complete. I certify that I have not nor will not withhold any information that is reasonably requested. I understand that withholding information can have a serious negative impact on the quality of services provided, including resulting in an inaccurate diagnosis and/or care. This includes but is not limited to prior medical, mental health, or behavioral history; family history of potentially related medical, mental health, or behavioral symptoms; pre-natal use of alcohol, drugs, or tobacco; pre-natal and birth abnormalities or incidents; child abuse or injury; injuries to the head; history of cancer or blood disease, etc. For patients seeing Dr. Richard New, I acknowledge an understanding that Dr. New is a Board-Certified Psychiatrist. His specialty area is with the adult population. He does have several years' experience working with children and adolescents; however, he is not certified in the sub-specialty area of children and adolescents. If I will receive any community-based services from IHCC (i.e. Case Management, Peer Support, Family Support, CBRS, etc.), I authorize transportation for myself and/or family member during services times, including transportation to and from appointments or activities requiring service participation as appropriate and necessary.
Acknowledgement*

I have read and agree with the Medical Consent statement

Release of Information
I acknowledge that IHCC will use my information for the purpose of diagnostics, assessment, payment, and health care operations. I authorize IHCC, and any staff member involved in my care, to release medical information and supporting documentation of the same as compiled in my medical records during the time of services or reasonable follow-up period to any organization which is or may be liable or responsible for payment of charges associated with my care and for all other purposes of benefit of payment. I acknowledge that data from my patient records will be accessible to all health care, social service providers, and educational institutions participating in my care and treatment, including but not limited to physicians, psychiatrists, therapists, diagnosticians, nurses, technicians, and such other health care or mental health care agencies involved in my care with a valid release. This information may also be provided to educational institutions in which the patient is enrolled upon request. I further acknowledge that my medical records may be utilized in IHCC’s utilization review. I also acknowledge that information contained in my medical records may be extracted and compiled for research purposes and the aggregated results (without individually identifying me) may be released to the public. I acknowledge that my medical records may also be made available to governmental agencies as required by law. I acknowledge that patient medical records may be stored electronically and made available through secure computer networks to IHCC staff personnel.
Acknowledgement*

I agree to the Release of Information Terms and Conditions

Informed Consent and Notice of Privacy Practices
IHCC provides all individuals receiving direct services a copy of our Informed Consent document. This document addresses an individual's rights and responsibilities when receiving Mental Health Services with IHCC.

Please review and download a copy of Innovative Health Care Concept's Notice of Privacy Practices (NOPP).

I understand that I can request a copy of IHCC's Notice of Privacy Practices and Informed Consent documents at any time. Furthermore, I understand that these documents are available for review at any time on IHCC's website located at www.ihccinc.com at the bottom of any page.

Review and download the Informed Consent document.

Review and download our Notice of Privacy Practices.
Acknowledgement*

I have reviewed and understand the statement on Informed Consent and Notice of Privacy Practices.

Telemental Health Sessions
In the event you or your practitioner opt for Telemental Health Sessions, please review the following.

Overview of Telemental Health Sessions
Telemental Health refers to psychotherapy services that occur via a virtual, electronic platform. Providers are required to use platforms that meet specific HIPAA compliance requirements and are designed to protect your personal health information. Innovative Health Care uses GoToConnect and Doxy.me, electronic platforms designed for the provision of telehealth services. Both platforms meet all requirements for HIPAA compliance and therefore, are acceptable platforms for the provision of Telemental Health services.

Access to Care
In order to participate in a Telemental Health session, you and your provider must first determine if you are a candidate for this method of service delivery. Some reasons for the provision of Telemental Health services may be because you live in a rural area and do not have access to traditional methods of service delivery. You may have a condition that prevents you from leaving your home, or you may have limited transportation that prevents you from accessing face to face sessions. In order to access Telemental Health services, you must have the following:
- The ability to see and hear through an electronic device such as your laptop, desktop computer, tablet, or smart phone
- A private and safe space to participate in the session
- Enough knowledge of electronic systems to access the Telemental Health site and navigate appropriate options
- An email address
Conflict of Interest
Our clinicians do not receive a financial benefit for delivering Telemental Health services versus traditional face to face sessions. Reimbursement is the same regardless of the treatment location and modality.

Insurance/Payment Policy
Your insurance will be billed for Telemental Health services the same as if you were meeting face to face. The only indication your service was delivered via virtual means will be a modifier used during billing of “GT.”
I authorize the release of any medical information necessary to process any claim. I permit a copy of the authorization to be used in place of the original. This authorization may be revoked by either me or the Employer Benefits Manager at any time in writing.

Medical Consent Policy
I consent to the services which may be performed as a patient, on an outpatient basis, within the scope of practice authorized under the licenses of the respective licensed providers. In agreeing to participate in virtual counseling sessions, I understand that there may be technical difficulties that will need to be resolved and that, even though IHCC uses a secure two‐way real time interactive telemental health system, as with any electronic system, there is the risk of data breach and my personal health information may be at risk of exposure. I understand that I can terminate my sessions at any time.

Download a copy of the Telemental Health Sessions Form document (PDF document).
Acknowledgement*

I have reviewed and understand the statement on Telemental Health Sessions and accept the Insurance/Payment and Medical Consent Policies.

Certification of True and Correct Information
I certify that the information given or will be given by me or upon my behalf is true, correct, and complete. I certify that I have not nor will not withhold any information that is reasonably requested. I understand that withholding information can have a serious negative impact on the quality of services provided, including resulting in an inaccurate diagnosis. This includes but is not limited to prior medical, mental health, or behavioral history; family history of potentially related medical, mental health, or behavioral symptoms; use of pre-natal use of alcohol, drugs, or tobacco; pre-natal and birth abnormalities or incidents; child abuse or injury; injuries to the head; history of cancer or blood disease, etc.
Acknowledgement*

I agree with the Certification of True and Correct Information statement

Signature and Form Submission

Sign and submit forms packet to Innovative Health Care
I hereby certify and state that I have read, and that I fully and completely understand the conditions for services and all acknowledgements above, and that I sign knowingly, freely, and voluntarily. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained based upon the diagnoses or results from assessment or testing completed. I further certify that the information I provide is true, correct, and complete, and certify the foregoing acknowledgements, understandings, and certifications.
Date

MonthDayYear
Signature*

Signature of Patient or Parent/Guardian Clear
Name of Signee

First NameLast Name
If you are experiencing thoughts of harming yourself or others, or if you are experiencing an emergency, please call 911. If you feel you are not in immediate need of emergency services, but you are experiencing a crisis, please contact our office immediately at (208) 523-6727 during business hours or contact our crisis phone at (208) 589-IHCC (4422) if after hours. You may continue to submit your application, but please contact our office if you feel you need assistance immediately.
Pediatric Symptom Checklist (PSC-35)

As you have indicated that the patient is a child between the ages of 3 and 17, after submitting this form you will be re-directed to the PSC-35. If the patient is 12 years or older, you will also be presented with the PHQ-9 depression screener and the GAD-7 anxiety screener.

The Pediatric Symptom Checklist (PSC) is a 35-item parent/caregiver-reported psychosocial screener designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. It is very important that you complete and submit this screener as the final step in initiating services with us.
Assessment and Screener forms

You will now be directed to a page with the WHO Dissability Assessment Schedule and the GAD-7 anxierty screener and the PHQ-9 depression screener form. Please click submit to continue. It is very important that you complete and submit these forms as the final step in initiating services with us.
Patient Health Questionnaire (PHQ-9)

You will now be directed to the short Patient Health Questionnaire depression screener form. Please click submit to continue. It is very important that you complete and submit this form as the final step in initiating services with us.
After clicking the submit button do not close the browser or use the back button until the "Thank You" confirmation page has appeared. Doing so may cause submission failure. It may take several moments for the form to be successfully submitted.
After clicking the submit button you will be re-directed to the PSC-35. Do not close the browser or use the back button until the PSC-35 page has appeared. Doing so may cause submission failure. It may take several moments for the form to be successfully submitted and be re-directed.
After clicking the submit button you will be re-directed to the WHODAS 2.0. Do not close the browser or use the back button until the WHODAS 2.0 page has appeared. Doing so may cause submission failure. It may take several moments for the form to be successfully submitted and be re-directed.
After clicking the submit button you will be re-directed to the PHQ-9 depression screener. Do not close the browser or use the back button until the PHQ-9 page has appeared. Doing so may cause submission failure. It may take several moments for the form to be successfully submitted and be re-directed.
Should be Empty:

IHCC Intake Packet

IHCC Admission Packet

Policy Regarding Unsupervised Minor Participants

Parent Conflict Disclosure

Payment and Insurance Information

Primary Care Practitioner Notice

Release of Information (ROI)

Distribution of Completed Evaluation

Psychological Testing Screening Form

Patient Medical Questionnaire

Patient History Questionnaire

Terms and Conditions of Service

Signature and Form Submission