TMS New Patient Registration Form

Date*

Date

Patient Name*

Date of Birth*

Date

Best Contact Phone #*

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Provider (Primary Doctor)

Primary Care Provider Phone #

Emergency Contact*

Emergency Contact Phone #*

Primary Insurance Company

Insurance ID Number

Insurance Subscriber's Name

Date of Birth of Subscriber

Date

I have ready an understand the statement*

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Informed Consent for Treatment

I agree and consent to participation in the health care services offered and provided by TMS Medical of the Hudson Valley, PC d/b/a Clearwave TMS Medical or Kimberly Robinson, M.D. Adult, Child and Adolescent Psychiatry, PLLC. I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within 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.

I have read and understand the statement*

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Notice of Privacy Practices

Linked here is our Notice of Privacy Practices. By signing below, you acknowledge that you have read, understand, and agree to Clearwave TMS Medical's Privacy Practices.

I have read and understand the statement*

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Clearwave Mental Health's FINANCIAL POLICY

Charges for TMS Therapy:

1.Transcranial Magnetic Stimulation ("TMS") therapy is provided by Clearwave TMS Medical ("Clearwave""). The cost for TMS therapy may vary depending on the treatment protocol prescribed for you. Clearwave's standard fee schedule is:

Initial Motor Threshold: $950.00 per unit

TMS Treatment: $750.00 per unit

Repeat Motor Threshold: $900.00 per unit for Repeat Motor Threshold

2. The typical course of treatment is 36 sessions. Additional treatments may be required for maximum benefit.

Cancellation Policy

1. In order for TMS Therapy to be effective, it should be performed on a routine basis for the complete treatment protocol of approximately 36 sessions. For self-pay patients, we will refund payment ONLY if we receive notice of cancellation at least seven (7) days before the date your initial (acute phase) treatment is scheduled to begin. No refunds will begiven within seven (7) days before you are scheduled to start the initial, acute phase, or treatment block.

2. Missing any treatment could affect your response to TMS and is not advisable. If you fail to cancel a particular day's TMS treatment within 24 hours of that treatment, you will be charged a cancelation fee of $50.00. Clearwave, in its sole discretion, may choose to waive or reduce this cancellation fee, however, any waiver or reduction in cancellation fee shall not be deemed a change in the Cancellation Policy and Clearwave reserves the right to enforce its Cancellation Policy on all subsequent missed treatments. Please be advised that most insurance companies do not reimburse for missed appointments and therefore you will likely be personally responsible for any assessed cancellation fee.

Payment Requirements:

1. All patients must have a valid credit card on file while undergoing TMS therapy. By signing this acknowledgement, you hereby provide TMS HV the authorization to charge your credit card for all sums owed at the time they become due, including applicable deductibles, copays, co-insurances and balance bills.

2. The patient is ultimately responsible for payment for TMS therapy. We accept most forms of payment. Payment for TMS therapy should be made to TMS Medical of the Hudson Valley, P.C. Returned checks will becharged the entire amount plus a $25 return check fee. Late payments will be charged interest at the rate of 1% per whole or partial month the payment is overdue, or 5% of the total bill, whichever is greater.

3. If you fail to timely make required payments, Clearwave reserves the right to pursue any and all means to collect outstanding payments. If Clearwave incurs any attorneys' fees and costs in its collections efforts, you shall be responsible for reimbursing Clearwave for all attorneys' fees and costs incurred to the extent permitted by law*.

*If any collections efforts proceed to court, this provision shall be interpreted as a prevailing party fee provision.

Patient Acknowledgement:

I acknowledge I have read this document and have been given an opportunity to ask questions. My questions have been answered to my satisfaction. A copy of this form has been made available to me.

Patient or Guardian's Signature*

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Release of Information - I hereby authorize Clearwave to as needed and/or requested*

Release any applicable mental health information to my primary care providerRelease only applicable substance abuse information to my primary care providerNot to release any information to my primary care provider

Forms:

If you require legal, financial, or insurance forms to be completed by a clinician, you will be charged and billed for the time that clinicians take to fill out the requested documents.

I have read and understand these statements*

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Credit Card Authorization Form

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

My Products*

Clearwave TMS Medical ServicesCredit Card will not be charged until services are rendered.

$0.01

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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

Signature*

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