Fillable Form 19355: (Please Print) FORM INFORMATION CLIENT NEW (Cornerstone Therapy, PA)

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Form 19355: (Please Print) FORM INFORMATION CLIENT NEW (Cornerstone Therapy, PA)

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CO
RN
ERSTONETH
ERAPYAND
WELLNESS
(610)616‐5935
639SwedesfordRoad
,
Malvern
,
PA
19355
996OldEagleSchoolRoad,Suite1105,Wayne,PA19087



LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
ADDRESS:
CITY:
STATE:
ZIP:
GENDER: Male Female
MARITAL STATUS:
Single Married Partner
Divorced Separated OTHER
PHONE:
WORK PHONE: CELL PHONE:
DATE OF BIRTH:
/
/
CONTACT E-MAIL:
WHO REFERRED YOU TO
Cornerstone Therapy and Wellness, LLC?
PATIENT EMPLOYER INFORMATION: Employed Student OTHER
COMPANY/SCHOOL:
OCCUPATION:
SAME AS ABOVE
LAST NAME: _ FIRST NAME: MIDDLE INITIAL:
ADDRESS: CITY:
_ STATE: ZIP:
GENDER: Male Female MARITAL STATUS: Single Married Partner Divorced Separated OTHER _
PHONE: _ WORK PHONE: _ CELL PHONE:
DATE OF BIRTH:
/
/
RELATIONSHIP TO THE PATIENT:
EMPLOYER INFORMATION:
Employed
Student
OTHER
_
CONTACT E-MAIL
:
COMPANY/SCHOOL: _
OCCUPATION: _
INSURANCE COMPANY:
INSURANCE ID # OF PATIENT:
INSURANCE CO PHONE: _ COPAY:
EMERGENCY CONTACT NAME:
PHONE NUMBER:
IN ORDER TO FILE YOUR INSURANCE FOR YOU, WE REQUIRE THAT YOU CHECK EACH BOX AND
SIGN THE FOLLOWING SIGNATURE-ON-FILE FORM. (Including EAP)
I authorize release of my information and claim submissions to all my insurance carriers.
I unde rstand that I am responsible for my or de pe nde nts bill and it is my responsi bility to confirm my
coverage and be ne fi ts. For any reason the submitted claims are not paid within 45 days of the date of
service, I will become responsible for the entire bill.
I authorize
Cornerstone Therapy and Wellness
act as my agent in helping me obtain
payment from my insurance carriers.
I hereby authorize payment directly to Cornerstone Therapy and Wellness, if any, otherwise
payable to me for their se rvi ces as describe d, realizing I am responsible to pay non-c overed services.
Signature: ____________________________________________________________________ Date:
/
/
1
|Pag e
IN
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A
UT
H
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I
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N
PRIM
A
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IN
S
UR
A
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E
IN
ORM
A
TION
RESPONSIBLE PARTY
INFORMATIO
N
NEW
CLIENT
INFORMATION
FORM
(Please
Print)
click to sign
signature
click to edit
CO
RN
ERSTONETH
ERAPYAND
WELLNESS
(610)616‐5935
639SwedesfordRoad
,
Malvern
,
PA
19355
996OldEagleSchoolRoad,Suite1105,Wayne,PA19087
I (Patient Name/Parent/Guardian) ________________________________________________, have read the
statement below and agree by the terms and conditions.
We will make your payment as easy and convenient as possible. You may pay your copay or
deductible by cash, check, credit card or debit card. We require a credit card on file to
supportthe
cancellation policy.
INITIAL:______
I understand that there is a 3% surcharge for every credit/debit card transaction.
Exp. Date:Credit Card/Debit Card #: xxxx xxxx xxxx ________________ (Last 4 #’s)
Card Type:
Visa / MasterCard / Discover
(circle one)
INITIAL: _____
_
I understand that a 24 hr notice is needed
for any cancellations or I will be billed the
following fees:
Therapy:
Psychiatry Med Check:
Psychiatry Evaluation:
$50.00
$75.00
$180.00
This is not a
billable charge
to your insurance
company. All
cancellations need to be
made
by
phone. I also understand that there will be a $30.00 charge for all returned checks.
I authorize Cornerstone Therapy and Wellness to charge my co pay, outstanding balances and/or
cancellation fee charged on my account to the provided credit card number/debit card or any replacement
credit card that I supply during my treatment period. I also understand that any balance on my
account ultimately becomes my responsibility as
well as the primary insurance policy holders
.
Signature: ________________________________________________________________________ Date :
/
/
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Credit card information
: (
this section will be detached and destroyed once entered into our (PCI DSS) compliant system
)
Credit/Debi t Card # ______________________________________Expiration Date: ______
/_______/
________
Name on Card: ______________________________________________Security Code: _____________
Card Type:
Visa / MasterCard / Discover
(circle one)
2
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F
INAN
C
I
A
L
A
C
C
E
P
T
AN
C
E
F
O
RM
click to sign
signature
click to edit
CORNERSTONE
THERAPY
AND
WELLNESS
639SwedesfordRoad
,
MA
LVER
N,
PA
19355
CON
SE
N
T TO T
R
EATME
N
T
:
PRESCRIPTION
REFILLS:
(610)616‐5935
996OldEagleSchoolRoad,Suite1105,Wayne,PA19087
I authorize, request, consent and agree to receive treatment /services from Cornerstone Therapy and
Wellness. I understand that I can withdraw this consent to treatment at any time. A withdrawal of consent will
be done in writing and will include the reason for withdrawal.
I understand that the office doe s not handle any of the following: work grievances, lawsuits, custody disputes,
disability determinati ons, or any other legal admi nistrati ve proceedings, including work excuses and request
for change in job con diti ons.
As the policy holder and/or patient fully understand that I am directly responsible for payment to C o r n e r s t o n e T h e r a p y
and Wellness for the entire services rendered to me. I also understand that my insurance is an
agreement between me and my insurance company. As a courtesy, Cornerstone Therapy and Wellness,
will file your insurance claims for me. For any reason, the submitted claims are not paid to them within 45 days
of the date of service, the policy holder and/or patient will become responsible for the entire bill. If such
an event does arise, an itemized bill will be given to me to help process my claims. This is a standard
practice within the Mental Health Industry.
I understand there is a fee for a copy of my record if the request comes from anyone other than another state
licensed physician or mental health practitioner. (M.D., LCSW, PsyD, LPC, etc.) This fee is outlined and
regulated by the PA Department of Health and is available on their web site. (www.health.pa.gov)
I understand that my physician will give me adequate prescriptions until my next scheduled visit and that is
my responsibility as the patient to make the next appointment in the correct time frame to be able to refill my
prescription. I also fully understand no refills will be given if I have not seen my physician within 90 days of
my last appointment. I also understand no re fi lls will be processed if I have missed or cancelled more than
one appointment. I understand that the office does not mail in prescriptions. I also understand controlled
substances prescriptions will not be replaced if lost or stolen
By my signature below, I acknowledge that I have read, understood and agree to all the above.
Signature: ________________________________________________________________________ Date:
/________/
3
|Pag e
FEES
FOR
ADDITION AL
SERVICES:
GUARANTEE
OF
P
AYM
ENT:
L
IM
IT
O
F P
R
A
C
T
I
C
E
:
A
KNOWLEDGEMENT
O
RE
EIPT:
read, review
and understand the documents fully.
Policy"
and"Teletherapy Informed Consent"
documents
and confirm that I
have had adequate opportunity to
Notice,"
"Financial Policy,"
"Electronic Communication Agreement,"
"Patients’ Rights and Responsibilities
I acknowledge that I have received from Cornerstone Therapy and Wellness, the
"Federal HIPAA Privacy
click to sign
signature
click to edit
CORNERSTONE
THERAPY
AND
WELLNESS
(610)616‐5935
639SwedesfordRoad,Malvern,PA19355
996OldEagleSchoolRoad,Suite1105,Wayne,PA19087
Reason for this policy:
To be effective, counseling and psychotherapy need to take place on a regular basis. The best
results occur when appointments are consistently scheduled and attended regularly. Additionally, an
appointment time reserved for you means that it cannot be used for someone else. It is reserved for
you and/or your family.
If the policy holder and/or patient do not notify your Therapist/Psychiatrist by phone of your
intention to cancel or reschedule 24hrs in advance, you will be charged the following fees:
Therapy: Psychiatry Med Check: Psychiatry Evaluation:
$50.00 $75.00 $180.00
Cancelling or re-scheduling within 24hrs allows the therapist an opportunity to schedule
someone else for that time slot. This is important because others may be on a waiting list
for or preferred your time slot.
If you reschedule to a later time of the day or week of your scheduled appointment and if
there is an opening, the cancellation fee will be waived.
1)
You will never be charged for a cancellati on that is made more than 24 hours in advance of your
scheduled appointment time.
2)
This cancellation policy is standard in the mental health field.
3)
If you simply do not show up for a sche dule d appointment, you will be charged for the missed
appoi ntment.
4)
This fee is
not
billable to your insurance company and is your out-of-pocket responsibi lity.
5)
Arriving late without notification: Your therapist will wait for you for 15 minutes after which they
will assume you are not coming and may leave the office. In such a case, you will be charged for a
missed appoi ntment.
6)
On occasion, there will be understandable reasons for missing appointments, but, exceptions to
this policy will be rare. In the e vent of illness or work emergency, a phone sessi on is an opti on. There
is no charge for missed appointments due to snow conditions or declared states of emergencies.
If you have questions about this cancellation policy, you should discuss this with your therapist at the
start of therapy. Please sign below to indicate you have read, understand, and agree to abide by our
cancellation policy. Thank you.
Signature:
Date:
4
|Pag e
24
Hour
Cancellation
Policy
click to sign
signature
click to edit
CORNERSTONE
THERAPY
AND
WELLNESS
(610)616‐5935
639SwedesfordRoad,Malvern,PA19355
996OldEagleSchoolRoad,Suite1105,Wayne,PA19087
This
is
not
a
request
for
patient
records.
Authorization
to
Disclose Personal
Health
Information
to
Primary
Car
e
Physicia
n
PATIENT INFORMATION:
LAST:
FIRST:
MI:
BIRTHDATE:
DATE:
PRMARY
C
ARE
PROVIDE
R
INFORMATION
:
PHYSICIAN/PRACTICE NAME:
PHONE:
FAX:
ADDRESS CITY/STAT E/ZIP
MENTAL HEALTH PROVIDER INFORMATION: (Information below to be completed by therapist or physician)
Dear Primary Care
Provider,
I am sending this form to notify you that I am currently seeing
your patient in a therapeutic setting and to provide our offices with
a release of information to facilitate communication and to
coordinate services in regards to client care. If further information is
desired, please contact me at your convenience.
This is NOT a
request for you to send us medical records.
MAILIN
G ADDRESS:
Cornerstone Thera
p
y and Wellness
639 Swedesford Road, Malvern, PA 19355
996 Old Eagle School Road, Suite 1105 Wayne, PA 19087
Phone: (610) 616-5935
Fax: (484) 318-7166
www.cornerstonetherap y.com
THERAPIST NAME (please print)
CLINICAL INFORMATION:
REASON FOR RELEASE:
DIAGNOSIS: MEDICATIONS:
T
REATMENT PLAN(S) OR
RECOMMENDATIONS:
CONSENT AND RELEASE:
I authorize the exchange of my personal health information (PHI) regarding my clinical care needed to
coordinate treatment with my primary care physician. I understand that my records are protected under the
Federal and specific State confidentiality laws and regulations and cannot be disclosed without my written
consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at
any time except to the extent that action has been taken in reliance on it and that this consent expires automatically
as described below. Information to be released includes diagnosis, treatment procedures and details of my
condition which help to coordinate treatment. I further acknowledge that the information to be released was
fully explained to me and this consent is given of my own free will. This release is valid for one year after last
contact and I may cancel it in writing at any time.
I Do Consent:
SIGNATURE(S): DATE:
I do not consent to th e rel eas e and exchange of any informati on regardi ng my cl ini cal
car e to my primary car e physi ci an.
I Do N ot Consent:
SIGNATURE(S):
DATE:
5
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Directions:
Malvern Location: 639 Swedesford Road, Malvern, PA 19355
We are located in the Swedesford Corporate Center on the corner of Phoenixville Pike and Swedesford Road. As
soon as you pull in the parking lot off of Swedesford Road, our
entrance is located directly on the front left-hand
side of the building.
Wayne Location: 996 Old Eagle School Drive, Suite 1105, Wayne,
PA 19087
(When entering address in google maps, Waze or any other GPS device, please include the suite #)
Our entrace is located off of Devon Park Drive (Evolve West corporate center). As soon as you pull into the
parking lot drive past our building (996) and make a right after the first speed bump. Our entrance is the second
entrance on the right hand side. (Letter G and Suite 1105 located on outside glass door)
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Form 19355: (Please Print) FORM INFORMATION CLIENT NEW (Cornerstone Therapy, PA)

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Completed 31 January 2021

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