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  • PSYCHOLOGICAL ASSESSMENT FORM

    PSYCHOLOGICAL ASSESSMENT FORM

    (CHI/Franciscan forms for bariatric procedure)
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    PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC

    For telemedicine (Zoom) appointments:

    Thank you for scheduling your virtual Zoom appointment for a psychological evaluation for bariatric surgery. 

    We need your paperwork completed 3 days prior to your appointment or it will be canceled. 

    You must email a copy of your picture ID and copy of your insurance card front and back to info@horizonviewhealth.com

    If you would like to be put on a cancel list, please indicate in your email and this can only happen if we receive your paperwork asap. 

    A zoom invite will be sent to you prior to your appointment please check 24 hours  before that to make sure you have received the invite. (Please remember to look in your spam folder)

    Patients are responsible to call their own insurance to check if they have behavioral health and telemed coverage for this visit.  If you have a co-pay, please call after your appointment to pay over the phone.

    If you are unable to keep your appointment, please call us within 24 hours of appointment to cancel. You can call 253-268-3345.

    If you do not make your appointment, you will be charged a $75 No-show fee automatically on the credit card added on file when the appointment was booked.

     

     

    For In office appointments:

    Thank you for scheduling an in-office appointment for a psychological evaluation for your bariatric surgery. 

    You have the option of completing this paperwork online 3 days before 

    Or

    Arriving 30 minutes early to complete paperwork in office. If your paperwork is not completed by your appointment time, you will be asked to reschedule.  

    You must bring with your picture ID, your insurance card and your copay, if you have one.

    If you would like to be put on a cancel list, please indicate in your email and this can only happen if we receive your paperwork asap. 

    Patients are responsible to call their own insurance to check if they have behavioral health for this visit. 

    If you are unable to keep your appointment, please call us within 24 hours of appointment to cancel. You can call 253-268-3345.

    If you do not make your appointment, you will be charged a $75 No-show fee automatically on the credit card added on file when the appointment was booked.

     

    Sincerely,

    The HorizonView Health Reception Staff

    Address: 1408 3rd St SE Suite 200, Puyallup, WA 98372

    Phone: 253-881-1490 

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  • PATIENT INTAKE FORM

    Note: This form is HIPAA compliant and secure
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  • Responsible Party

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  • Primary Insurance

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  • Secondary Insurance

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  • Emergency Contacts

  • Secondary Emergency Contact (if applicable)

  • My Personal Weight Journey

  • Take a moment to answer the following questions about your weight, motivations and challenges to help guide conversations with your health care professional about a weight-management plan that fits your lifestyle.

  • Personal Information

  • Weight-related conditions

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  • *This is not a complete list of all possible weight-related conditions.

  • LIFE MILESTONES/EVENTS & WEIGHT

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  • WEIGHT-LOSS/MANAGEMENT EFFORTS

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  • CURRENT EATING & ACTIVITY ROUTINES

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  • Patient Health Questionnaire

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  • Adverse Childhood Experience (ACE) Questionnaire

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  • Consent of Treatment

  • CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

    FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

    RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

    By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.

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  • Notice of Privacy Practices Acknowledgement

  • This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.

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  • THERAPY LATE CANCELLATION AND NO-SHOW POLICY

  • This policy has been established to provide the highest level of counseling service to all our clients. It has been proven that consistent attendance provides for the greatest opportunity for success.
     
    By providing us with enough notice of cancellation, we may be able to accommodate other clients with your appointment time. Please provide our office with a 24-hour notice to change or cancel an appointment.
     
    Clients who do not provide a 24-hour notice to cancel or change a scheduled appointment will be responsible for a $75.00 late cancellation fee. This charge cannot be billed to insurance.
     
    Clients that do not contact us and do not attend their scheduled appointments are considered no shows. A $75.00 no show fee will be charged. This charge cannot be billed to insurance. If you do no-show, the $75.00 will automatically be charged to the credit card on file.
     
    When late cancellations and/or no shows become excessive, the therapist then has the right to terminate the relationship. Two no shows and/or late cancellations over the year would be considered excessive. This policy is effective January 1st, 2021. We do understand that emergencies arise and that it may not be possible to give such a notice. Exceptions to the late cancellation and no-show policy with be determined by our office.
     
    I have read and understand this policy.

     

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  • Telehealth Consent Form

  • A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

    I understand that:

    I can decline the Telehealth service at any time without affecting my right to future care or treatment.
    If I decline the Telehealth services, the alternative option would be in-person services.
    The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
    I will have access to all medical information resulting from the Telehealth service as provided by law.
    The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
    I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover. By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
    I have read this document carefully, and my questions have been answered to my satisfaction. I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.

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