New Patient Information Dr. Parker

The following information pertains to my financial policy. I hope this will answer any questions you may have, but if you do have any questions or special concerns please do not hesitate to discuss them with me at the first session. Please acknowledge your understanding of this policy by signing at the end of this form. If you would like a copy of this form for your records, I will be happy to provide one for you.

1. My fee is $170.00 per therapy hour and $190.00 for couples or family sessions, payable at the end of each session. The usual therapy hour consists of 45-50 minutes. The fee for the initial diagnostic session is $195.00. Charges for consultations outside the usual therapy hour (i.e., school observations, hospital visits, depositions. etc will be determined on an individual basis.

2. Payment is expected at the end of each session. Please discuss exceptional circumstances with me at the first session. Collection of insurance benefits or any other arrangement regarding third party payment is your responsibility. However, I will file insurance on your behalf. After the office manager verifies your insurance eligibility and level of benefits, I will gladly accept only the co-payment. Until that time, please plan on paying the full amount. My office verifies insurance benefits in an attempt to obtain accurate information regarding your co-payment and/or deductibles. However. it is very common for insurance companies to pay differently than what they quoted at the time of your visit. For that reason, you may receive a bill for services rendered if your insurance company does not reimburse as anticipated. If your managed care company requires authorization for our sessions. I will complete all necessary paperwork to obtain them. However, my office cannot adequately track number of sessions used for each authorization. Therefore, to avoid any disruption in your reimbursement, it is your responsibility to monitor the number of sessions we have used and to notify me when we are about to exceed those authorize. I can submit additional clinical information to obtain more sessions.

3. Since your appointment time is reserved for you, please notify me as soon as possible if you find that you must cancel an appointment. Appointments not canceled with at least 24 hours notice will be billed at the usual fee of $170.00 or $190.00 Missed appointments cannot be billed to the insurance company. You may leave a message with my answering service after hours and on weekends if you need to cancel an appointment. Full Slate. the calendar I use. will email 72 hrs, 24 hrs in advance to remind you. If it fails to do so you still bear responsibility to cancel.

Statement of Confidentiality: Confidentially is protected as described in HIPAA regulations (See Attached Under Georgia law communications between patients and psychologists are confidential, and under ordinary circumstances this privilege can be waived only by the patient. However, there are three clear exceptions in which a psychologist is legally and ethically bound to break confidentiality: (1) the patient is imminently dangerous to himself or herself, (2) the patient is imminently dangerous to others and/or has made specific threats to harm an identifiable third person, and (3) actual or suspected incidents of child or elder abuse. Although legally and ethically bound to break confidentiality under the aforementioned circumstances, I will not do so without attempting to discuss it with you. I acknowledge responsibility for all fees incurred. and if it is necessary. I consent to have my account collected through an attorney or collection agency. I also agree that I will be responsible for all costs of litigation. including attorney's fees. I have read and understand the above policies.

Patient's Signature

Today's Date

MonthDayYear

Parent or Guardian's Signature of minor

Date

MonthDayYear

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cellphone

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email Address

example@example.com

Type a question

Marriage Status*

SingleMarriedDivorcedWidowed

Sex

MaleFemale

DATE OF BIRTH

MonthDayYear

AGE

Employer

Job Position

Is it okay for a message be left at home for you?

YesNo

Where would you prefer to receive messages?

Cellular PhoneHome PhoneOther

Referred by:

May I contact the person who referred you?

YesNoOther

Have you been treated for your current problem previously

Describe prior treatments

If so, Where?

When were you treated for this problem?

Next of Kin not living with you

Address of Closest Next of Kin

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Responsible Party/Spouse/Parent Information:

Name

First NameLast Name

Responsible Party's Date of Birth

MonthDayYear

SS #

Responsible Party's Home Phone

Please enter a valid phone number.

Responsible Party's Work Phone

Please enter a valid phone number.

Responsible Party's Mobile Phone

Please enter a valid phone number.

Insurance Carrier

Name of Insured

Insurance Company Phone Number

Insurance Group Number

Insurance Patients: Please read and sign the following assignment of benefits if you would like us to file your insurance for you. Release of Authorization/Assignment of Benefits Iauthorize the release of any medical/psychological information necessary to process my insurance claims. I authorize and request payment of medical benefits directly to my psychologist/psychiatrist. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.

Patient/ Parent or Guardian Signature

Date

MonthDayYear

Ann McKee Parker, Ph.D. Insurance Patients: Please read and sign the following assignment of benefits if you would like us to file your insurance for you. Assignment of Benefits I authorize Ann McKee Parker, Ph.D. to release any medical or other information necessary for the processing of insurance claims. I authorize payment of medical benefits to Ann Parker McKee, Ph.D. for services rendered. I accept personal responsibility for any balance remaining for services rendered. including those that may be determined "not medically necessary" by my insurance carrier.

Patient/ Parent or Guardian Signature

Date

MonthDayYear

Primary Care Physician Information

Name

First NameLast Name

Phone

Include area code

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you been a patient of this physician?

May we contact your physician?

For purposes of continuity of care. may we contact your physician to let him/her know of your visit today? Yes/No

I give permission to to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care, and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment.

Patient Name

First NameLast Name

Patient Signature

Date

MonthDayYear

Psychological Services Agreement for Electronic Communication

I give permission for Ann McKee Parker, Ph.D., and/or her staff to leave messages regarding appointments on voicemail and/or send appointment reminders via FullSlate.

With your consent and if not clinically contraindicated, Ann McKee Parker, Ph.D may provide services electronically, including using email, telephone, video conferencing (i.e. Face-time Routinely. scheduling occurs by FullSlate or by telephone. please call (404) 847-9560. Emailed may be used in the delivery of some services to augment or follow up on face to face or telephone sessions. In these cases, Ann McKee Parker, Ph.D may provide updates, invoices, account statements summaries, memoranda. education resources and/ or exchange information. Based on the nature of the services provided. these email communications may include information not only you, but others in your household and or others.

When consenting to the provision of services by telephone or electronic platforms, it is electronic means, the same degree of confidentiality provided during an in-person session is not possible. The limitation includes the possibility of interceptions of communications while these occurring. Ann McKee Parker. Ph.D. will make every effort to minimize any interruptions during video or telephone contact and requests you do the same (e.g. tablets, laptop and or desktop we would need you to turning off cell phone, locking the door, etc Towards this end. You agree to make theses efforts and further, to advise Ann McKee Parker, Ph.D., if someone comes into the room in which you are communicating with Ann McKee Parker, Ph.D. or if someone is within earshot. The benefits of using electronic communications and telephone may include avoiding contending with traffic, taking less time off, convenience and comfort, or you may be out of town and want to continue to receive services. Alternative to the provision of electronic or telephone services include in-person services only or local services from an available health service provider of the same or different discipline. Please keep in mind that other individuals (living in your home) may be able to access information, sensitive or otherwise, communicated electronically or by telephone. As noted, the information shared may be about others, not only you. Any communications provided by Ann McKee Parker, Ph.D. or by her administrative assistant are intended for you and not for others unless agreed to otherwise. By signing this Informed Consent, you are confirming to her that you have taken reasonable steps to secure your own electronic devices (mobile phone, tablets, iPad, desktop. laptops, or any other electronic(s) devises you have in your household or designated private area etc This includes having a confidential password and adequate firewalls.

You further agree not to allow others (e.g. household member or non-household members, etc to access to any communications sent to you from Ann McKee Parker, Ph.D. or her administrative assistant. unless agreement is reached in advance that the particular communication is appropriate to share with others. If you are out of state, it is illegal for psychologist to practice in a location you may be in at the time of service is delivered, even if you are resident od Georgia, unless the therapist obtains a temporary license. By signing this consent, you agree to advise Ann McKee Parker, Ph.D. for each telephone or video contact if you are no longer in Georgia.

Ann McKee Parker, Ph.D. does not consent to any recording of electronic session. (mobile phone, tablets, iPad, desktop, laptops, or any other electronic(s) devises you have in your household or designated private area etc

I have read and understand the above policies.

Patient's Signature

Date

MonthDayYear

Print Name

If applicable Guardian Signature

Psychological Services Agreement and HIPAA Signature Attachment

I have read. understand, and agree to abide by the terms and conditions set forth in the Psychological Services Agreement. and do hereby consent to participation in the treatment as described in the Agreement. I also understand that my participation is entirely voluntary and that I may withdraw my consent and treatment at any time I have been provided with the Georgia HIPAA Notice and understand. Iunderstand HIPAA is a federal law that provides privacy protections and assures patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires thatI provide you with a complete printed copy of the Georgia HIPAA Notice for use and disclosure of PHI for treatment. payment and health care operations. The Georgia HIPAA Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. We can discuss any questions that you may have about the procedures outlined in the Georgia HIPAA Notice.

Patient Signature

Date

MonthDayYear

Patient's Printed Name

Confidential Patient Medical History

Patient Name

First NameLast Name

Please list all of the patient's medical conditions, surgeries, major illnesses or injuries, family psychiatric history, drug abuse, suicidal thoughts/attempts.

Please list all past psychiatric meds (dosages and duration taken. if known)

Has the patient been diagnosed with Depression?

YesNoOther

Has the patient been diagnosed with Anxiety or a Panic Disorder?

YesNoOther

Substance Use History - Please specify amount and frequency Past Current alcohol 0 0 tobacco oO

alcohol

tobacco

marijuana

cocaine

opiates

stimulants

ecstasy

other

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