Thielman Forms

Dr. Samuel Thielman
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Marital Status
Who referred you to us*
Phone Cell*
Phone Home
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Employment
Describe the reason for evaluation*
Are you seeking only medication and/ or counseling?*
Previous psychiatrist hospitalizations and/ or mental health treatment*
Are you currently in crisis?*
Are you currently having thoughts of harming yourself/ suicide ideation?*
Current medications with dosage*
Do your currently have insurance or self pay*
Primary Insurance*
Secondary Insurance
Have you ever experienced any of the following? (check all that apply)*

Extreme depressed moodDramatic mood swingsRapid speechPanic attacksPhobiasSleep disturbancesHallucinationsUnexplained losses of timeUnexplained memory lapsesAlcohol/ substance abuseFrequent body complaintsEating disorderBody image problemsRepetitive thoughts (e.g obsessions)Repetitive behaviorsExtreme anxietyNone of the above
Have you tried any of the following? (check all that apply)*

MethamphetamineCocaineStimulants (pills)HeroinLSD/ HallucinogensMarijuanaPain killersMethadoneTranquilizers/ sleeping pillsEcstasyAlcoholNone of the above
Family Mental Health History. Check if applicable*

Alcohol/ Substance AbuseAnxietyDepressionDomestic ViolenceEating disordersObsessive Compulsive BehaviorSchizophreniaSuicide AttemptsNone of the above
Benefit Confirmation

Insurance
Name of Patient*
Insurance Company*
Subscriber ID
Group #
FORM MUST BE COMPLETED PRIOR TO APPOINTMENT OR THE FULL AMOUNT OF YOUR VISIT WILL BE EXPECTED IN FULL
Please have your insurance card in hand
WHEN YOU CALL YOUR INSURANCE COMPANY ASK THE FOLLOWING QUESTIONS:
"This is (YOUR NAME) and I am calling to get details about my behavioral health benefits."
1. Do I have a co pay or co insurance for OUTPATIENT Behavioral Health?
2. What is the amount I pay per visit?
3. What is my deductible? $
4. How much of my deductible has already been met?
As of Date

MonthDayYear
Date
5. When does my deductible period start? (Date each year)

MonthDayYear
Date
6. What is the effective date of my insurance policy? (Month/Day/Year)

MonthDayYear
Date
7. How many visits does my policy allow for OUTPATIENT Behavioral Health Per year?
8. If I need more outpatient visits, what do I do to obtain authorization?
9. Is there a yearly maximum for OUTPATIENT Behavioral Health?
10. Do I need an authorization for my visits?
11. How do I obtain an authorization?
12. Where and who should my provider mail claims to?
13. What is your EDI Payer number?
14. May I please have your name, your extension number and the Reference# for this call?
NOTE: Benefits Confirmation Form should be received by Biltmore medical prior to your first session in order for the office to verify your benefit. This allows our staff to calculate the payment you will be expected to make at the time of service. If this information is not received prior to your visit you will be responsible for the full fee amount until your benefits are verified or this completed form is received. Thank you.
Signature*

Clear
Date*

MonthDayYear
Date
Cancellation Policy

Please read and sign
If for any reason you are unable to attend your scheduled appointment you must call a minimum of 24-hours in advance. Charges arising from late cancellations or missed appointments without notice are not reimbursed by your insurance carrier, and will not be submitted to your insurer. Biltmore Medical is pleased to assist you by filing insurance on your behalf. An insurance policy is a contract between you and your insurance company. All deductibles, co-pays, and amounts not covered by your policy are your responsibility and you are asked to keep your account current at each visit. Our providers are participating providers with several insurance plans. However, you are ultimately responsible for payment of all services rendered, including those that are not covered by insurance.

Fees and Unpaid Balances: The fee for your first appointment schedule will be discussed with you at your initial consultation or prior to your appointment if you wish. After the first visit, charges vary based on the complexity, duration, and treatment rendered during your visit. Physician providers (Psychiatrists) bill services in a manner similar to other physicians-that is a charge for an office visit typically combined with a separate charge for psychotherapy. Telephone and written communications with your provider may be subject to charges based on the duration of the service. Fees for Psychological Testing, Genetic Testing, and certain Consultations to coordinate care will be charged as separate services. We ask that you keep your account.

Your rights as a Patient/Client: You have the right to ask questions about any procedure during therapy. You have the right to decide at any time to stop seeing your provider and if you wish, your provider will provide you with names of other qualified professionals you might prefer. You have the right to end therapy at any time without moral, legal, or financial obligation other than those already accrued.

Authorization and Consent for Treatment: I hereby grant my authorization and consent to treatment and procedures deemed appropriate and certify that no guarantee or assurance has been made as to the results which may be obtained. I also give my consent for my personal health information to be shared with any other clinicians within Biltmore Medical Associates to which I have been referred.
Initial
Date

MonthDayYear
Date
Insurance Authorization and Assignment: I hereby authorize Biltmore Medical Associates, to release information necessary to process insurance claims and request payments of benefits to be made to Biltmore Medical, for services rendered to my dependents or me. I understand that I am responsible for paying any required co-payments and deductibles at the time services are rendered. I hereby authorize my provider and Biltmore Medical Associates to release any information required by my insurance carrier to process insurance claims in the course of my examination or treatment. I authorize payment directly to the billing office for my provider and hereby assign payment for the medical benefits, if any, otherwise payable to me for services.
Initial
Date

MonthDayYear
Date
Self-Pay: I have no insurance coverage or I waive the use of insurance. Therefore, I understand that I am responsible for payment at the time services are rendered to me.
Initial
Only initial here if you will be 'Self Pay'
Date

MonthDayYear
Date
Signature of Patient or Legal Guardian/Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Benefit Confirmation

FORM MUST BE COMPLETED PRIOR TO APPOINTMENT OR THE FULL AMOUNT OF YOUR VISIT WILL BE EXPECTED IN FULL

WHEN YOU CALL YOUR INSURANCE COMPANY ASK THE FOLLOWING QUESTIONS:

Cancellation Policy